Textbook of Primary Care Dermatology [1st ed. 2021] 3030291006, 9783030291006

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Textbook of Primary Care Dermatology David Buckley Paola Pasquali Editors

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Textbook of Primary Care Dermatology

David Buckley  •  Paola Pasquali Editors

Textbook of Primary Care Dermatology

Editors David Buckley The Ashe Street Clinic Tralee Co. Kerry Ireland

Paola Pasquali Department of Dermatology Pius Hospital de Valls Valls Tarragona Spain

ISBN 978-3-030-29100-6    ISBN 978-3-030-29101-3 (eBook) https://doi.org/10.1007/978-3-030-29101-3 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

This book is dedicated to my wife, Áine, who is my greatest supporter and greatest critique.

Acknowledgements

A textbook such as this came about as a result of collaboration with many colleagues in general practice (GP), dermatology and plastic surgery over the past 38 years since I qualified in medicine in Dublin, and even before that as an undergraduate studying medicine in UCD. I learnt the meaning of hard work, empathy and passion from my parents and particularly my father, Dr Denis Buckley, who was a GP with an interest in dermatology in our local town for over 50 years. His motto was “work hard and play hard” which I try to follow. My mentors in GP training in Dublin including Prof Fergus O Kelly, Dr Manne Berber, Prof Bill Shannon and Prof Andrew Murphy all instilled in me a love of general practice. I spent 18 months working in hospital-based dermatology in Dublin after qualifying in medicine and received excellent teaching from some of the top Irish dermatologists at the time including Prof Sarah Rogers, Prof Frank Powell and Dr Sean O’Loughlin. My 2 years working in a rural mission hospital in “the bush” in Northern Kenya allowed me a wonderful opportunity to improve my surgical skills and knowledge of tropical medicine that was mostly learnt from my Kenyan doctor and nurse collogues to whom I am eternally grateful. I spent a year studying for the Diploma in Practical Dermatology in the University of Wales College of Medicine in the early 1990s and got a wonderful, structured education from some of the top UK dermatologists at the time including Prof Ronny Marks and Prof Andrew Finley. All my colleagues in the Primary Care Dermatology Society of Ireland (PCDSI), the Primary Care Dermatology Society (PCDS, UK), the Primary Care Surgical Association (PCSA) and the Association of Surgeons in Primary Care (ASPC, UK) have been wonderful support and encouragement to me over the years. Many of my colleagues and friends in these organisations (too many to mention individually—you know who you are) helped proofread all the chapters in this book. Particular word of thanks to Dr Johnny Loughnane and Dr Hilda Fennell O’Shea with whom I established the PCDSI and Dr Niall Maguire and Dr Tony O’Sullivan with whom I established the PCSA. Thanks also to my UK collogues who have encouraged and supported me over the years, especially Dr Laurel Spooner, Mr Vijay Kumar, Dr Jonathan Botting, all from the ASPC, and Mr Christy Chou from the PCDS. I have made many friends and met wonderfully supportive colleagues through the International Society of Cryosurgery (ISC) including Dr Gloria vii

Acknowledgements

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Graham, Prof Christos C.  Zouboulis, Dr Arthur Jackson and Mr Omar Maiwand. Thanks to all my GP colleagues in Kerry and in the South West Specialist Training Programme in General Practice who have supported me over the years and trusted me to look after many of their patients with difficult dermatology problems. No man is an island and I could not work without the cooperation and support of my hospital-based colleagues in dermatology, plastic surgery and pathology in both Kerry and Cork. My patients in GP and primary care dermatology have taught me so much, and their feedback and encouragement have maintained my interest and enthusiasm in these areas of medicine which I hope will continue for many years to come. Dr Paola Pasquali deserves special mention. She has been a friend and mentor over many years, and I am delighted to have her expert opinions and support in writing this textbook. A special word of thanks to all at Springer Books, especially Vijayasankara Gomathy Rajagopal, Leo Johnson and Grant Weston who have all been patient and supportive over the past few months in preparing the final manuscript for publication. Finally, I would like to thank my wife Áine and my 3 children who have put up with me over the past number of years with my head stuck in the laptop writing and rewriting draft after draft. Áine is my greatest critic and supporter. She has read every line of this textbook, checking for grammar and spelling errors that were all too frequent. I could not have done any of this without her love, support and encouragement. 25 May 2020

David Buckley

Contents

Part I Overview 1 Dermatology in Primary Care��������������������������������������������������������   3 David Buckley 2 History Taking and Examination ��������������������������������������������������   7 David Buckley 3 Investigations and Treatment in Primary Care Dermatology����������������������������������������������������������������������������  13 David Buckley 4 Structure and Function of the Skin������������������������������������������������  17 David Buckley 5 Terminology in Dermatology����������������������������������������������������������  21 David Buckley 6 Teledermatology ������������������������������������������������������������������������������  29 Paola Pasquali Part II Adnexal Disease 7 A Stepwise Approach to the Management of Acne in Primary Care ������������������������������������������������������������������������������  35 David Buckley 8 Oral Isotretinoin for Severe Acne ��������������������������������������������������  51 David Buckley 9 Polycystic Ovarian Syndrome (PCOS)������������������������������������������  59 David Buckley 10 Rosacea����������������������������������������������������������������������������������������������  65 David Buckley 11 Hidradenitis Suppurativa����������������������������������������������������������������  71 David Buckley 12 Hyperhidrosis (Excessive Sweating)����������������������������������������������  75 David Buckley

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Part III Papulosquamous and Eczematous Dermatoses 13 Atopic Eczema in Children ������������������������������������������������������������  83 David Buckley 14 Management of Eczema/Dermatitis in Adults������������������������������  97 David Buckley 15 Management of Psoriasis in Primary Care����������������������������������� 107 David Buckley 16 Seborrhoeic Dermatitis (SD)���������������������������������������������������������� 121 David Buckley 17 The Red Face������������������������������������������������������������������������������������ 127 David Buckley 18 Papulo-Pustular Rashes on the Face���������������������������������������������� 133 David Buckley 19 Lichen Planus (LP)�������������������������������������������������������������������������� 137 David Buckley Part IV Urticaria, Erythrema and Vesiculobullous Disease 20 Urticaria�������������������������������������������������������������������������������������������� 143 David Buckley 21 Allergic Skin Disorders�������������������������������������������������������������������� 151 David Buckley 22 Generalised Rashes in Adults���������������������������������������������������������� 161 David Buckley 23 Blistering Eruptions������������������������������������������������������������������������ 175 David Buckley 24 The Ageing Skin ������������������������������������������������������������������������������ 183 David Buckley 25 Skin Diseases in Pregnancy ������������������������������������������������������������ 191 David Buckley Part V Paediatric Dermatology 26 Paediatric Dermatology������������������������������������������������������������������ 201 David Buckley 27 Exanthems and Infectious Rashes in Childhood�������������������������� 209 David Buckley 28 Genodermatosis: Inherited Skin Diseases ������������������������������������ 219 David Buckley

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29 Congenital Nevi, Melanocytic Naevi (Moles) and Vascular Tumors in Newborns and Children������������������������ 225 David Buckley Part VI Infections, Infestations and Bites 30 Common Bacterial Skin Infections in General Practice�������������� 235 David Buckley 31 Fungal and Yeast Infection of Skin, Hair and Nails���������������������� 243 David Buckley 32 Cutaneous Viral Skin Infections ���������������������������������������������������� 251 David Buckley 33 COVID-19 and the Skin������������������������������������������������������������������ 259 David Buckley 34 Management of Warts in General Practice ���������������������������������� 265 David Buckley 35 Bugs and Bites���������������������������������������������������������������������������������� 275 David Buckley Part VII Regional Dermatology 36 Regional Dermatology �������������������������������������������������������������������� 285 David Buckley 37 Leg Ulcers: A Treatment Programme�������������������������������������������� 325 David Buckley 38 Wound Care�������������������������������������������������������������������������������������� 333 David Buckley 39 The Red Leg�������������������������������������������������������������������������������������� 341 David Buckley Part VIII Hair and Nail Problems 40 Hair Loss and Hair Growth������������������������������������������������������������ 347 David Buckley 41 Nail Problems in General Practice ������������������������������������������������ 361 David Buckley Part IX Lesion Recognition 42 Lesion Recognition�������������������������������������������������������������������������� 373 David Buckley

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43 Pigmented Lesions �������������������������������������������������������������������������� 379 David Buckley 44 Non-pigmented Lesions ������������������������������������������������������������������ 389 David Buckley 45 Cancer and Pre-Cancer of the Skin����������������������������������������������� 397 David Buckley 46 Dermoscopy for the General Practitioner ������������������������������������ 429 David Buckley Part X Pigment and the Skin 47 Disorders of Pigmentation�������������������������������������������������������������� 443 David Buckley 48 Skin of Colour���������������������������������������������������������������������������������� 449 David Buckley Part XI Disorders Due to Physical Agents, Systemic Conditions and the Mind 49 Photobiology and the Skin�������������������������������������������������������������� 459 David Buckley 50 Pruritus (Itch)���������������������������������������������������������������������������������� 467 David Buckley 51 Skin in Systemic Disease������������������������������������������������������������������ 475 David Buckley 52 Skin Problems Associated with Diabetes �������������������������������������� 489 David Buckley 53 Skin and the Mind (Psychodermatology)�������������������������������������� 495 David Buckley 54 Cutaneous Vasculitis������������������������������������������������������������������������ 503 David Buckley 55 Emergencies in Dermatology���������������������������������������������������������� 507 David Buckley Part XII Surgical Therapies 56 Local Anaesthesia for Skin Surgery ���������������������������������������������� 517 David Buckley 57 Simple Skin Surgery������������������������������������������������������������������������ 523 David Buckley

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58 Cryosurgery in Primary Care�������������������������������������������������������� 535 David Buckley 59 Cryosurgery for Warts in General Practice���������������������������������� 541 David Buckley 60 A Practice Nurse Led Cryosurgery Clinic������������������������������������ 553 David Buckley Part XIII Pharmacology and the Skin 61 Pharmacists and Skin Disease�������������������������������������������������������� 557 David Buckley 62 Emollients and Moisturisers ���������������������������������������������������������� 561 David Buckley 63 Steroids in Dermatology������������������������������������������������������������������ 567 David Buckley 64 Topical Immunomodulators (TIMs)���������������������������������������������� 575 David Buckley Part XIV Nurses, Patients, Courses and Websites 65 Nursing Care of the Dermatology Patient ������������������������������������ 581 David Buckley 66 Patient Information Leaflets (PIL)������������������������������������������������ 585 David Buckley 67 Useful Websites, Courses, Bibliography and Patient Support Groups ���������������������������������������������������������� 631 David Buckley Index���������������������������������������������������������������������������������������������������������� 637

About the Editors

David  Buckley  is a principal in general practice and GP trainer who has developed a special interest and expertise in dermatology and skin surgery. He obtained his basic medical degree from the National University of Ireland (Dublin) in 1982. He joined the Dublin Vocational Training Scheme in General Practice in 1983 and spent the next 3 years specialising in general practice which included 6 months in the dermatology department of the Mater Hospital, Dublin. After this, he spent 6 months training at the Dublin Skin and Cancer Hospital, Hume Street, Dublin. Dr Buckley then spent 2 years working as the chief medical officer in a large mission hospital in the north of Kenya with APSO (the Irish development agency) where he perfected his skills in surgery and tropical medicine. On return to Ireland in 1989, Dr Buckley established a new general practice combined with a primary care dermatology practice in his hometown of Tralee. Having begun on his own, the practice has since grown to include five doctors, three nurses, a clinical assistant and seven administration staff. He completed a year-long Diploma in Practical Dermatology in the University of Wales College of Medicine in 1990. He established the Solas Dermatology and Laser Clinic 2000 and changed the name to the Kerry Skin Clinic in 2018. Dr Buckley is a founding member of the Primary Care Dermatology Society of Ireland (1996) and the Primary Care Surgical Society (2012). He has been a member of the European Academy of Dermatology and Venereology since 1993. He has published eight scientific papers on community-based dermatology and cryosurgery in peer-reviewed journals, and this is his second book on primary care dermatology. He has also contributed chapters on two international textbooks on cryosurgery. He is an honorary lecturer in dermatology for the Irish College of General Practitioners and was awarded a fellowship of the Royal College of General Practitioners (London) in 2018 for his contribution to medicine. Paola Pasquali  is a dermatologist with a specialty in non-melanoma skin cancer treatment with special emphasis on cryosurgery, non-invasive imaging techniques and teledermatology. She is a Springer editor for Skin Cancer: A Practical Approach, Cryosurgery: A Practical Manual and Photography in Clinical Medicine. She is Past President of the International Society of Teledermatology and chairman of AAD International Affairs Committee and member of EADV School.

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Part I Overview

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Dermatology in Primary Care David Buckley

Key Points  • At least 15% of GP (general practitioner) consultations involve dermatology problems. • Dermatology in primary can be very different from that seen in hospital dermatology departments. • Most dermatology textbooks are written by hospital based doctors and tend to include rare and dramatic skin complaints that are not normally managed by GP’s. • GPs can manage their patients holistically, dealing not only with the physical problems, but also the psychological and social aspects of their skin problems. • Give realistic expectations as to how long it will take for a treatment to work.

1.1

Introduction

Skin, hair and nail problems are very common in the community. Studies have estimated that the overall proportion of the population with any form of skin disease was 55%, with 22.5% considered worthy of medical care (that is, moderate or severe) by a member of the primary care team such as a general practitioner, nurse practitioner,

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland e-mail: [email protected]

public health nurse or community pharmacist [1]. Skin diseases account for 12–23% of all symptoms based requests for advice from community pharmacists [2]. At least 15% of GP consultations involve dermatology problems [3, 4]. There are more diagnoses in dermatology (>2000) than in any other speciality in medicine. Despite this, there are only ten common dermatology problems that make up 80% of skin problems seen in general practice [5, 6] (Table 1.1). This list will change depending on the population studied. There are many elements that need to be accounted for like ethnicity, availability to diagnostics and treatment services among others [7]. Most GPs should be able to confidently diagnose and manage most patients with mild to moderate forms of these 10 problems. In general, when faced with an unusual rash or lesion it is more likely to be an unusual presentation of a common problem, rather than a rare dermatology diagnosis.

1.2

The Patient’s Perspective

The dermatology problem may be presented as the primary reason for the patient attending or may be part of a list of problems the patient brings to the GP. There are even situations where a patient may be embarrassed or reluctant to discuss their skin problems with their GP with the mistaken belief that the problem is trivial or that

© Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_1

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D. Buckley

4 Table 1.1  The 10 most common dermatological problems that make up 80% of skin problems seen in general practice • Eczema • Psoriasis • Acne • Urticaria • Rosacea • Skin infections (Bacterial, viral, fungal + parasitic) • Wound care including leg ulcer • Skin tumors (benign + malignant) • Lichen planus • Drug rashes

they should not be wasting their GP’s time. The patient may tag a significant dermatology problem onto the end a busy consultation dealing with other unrelated problems. It is good practice to establish all the reasons the patient is attending at the start of the consultation (“are there any other problems”) so the doctor can decide which problems are a priority and which may have to be left to another visit if there is not enough time. It takes time to properly examine the skin and a GP should have it in order to diagnose and propose solutions to the patient. Conditions like acne or psoriasis can be quick to diagnose but explaining the aetiology and the managment strategy to the patient is time consuming. Writing a quick prescription without having time to deal with the patient’s concerns, lifestyle changes and any non-prescription items is often doomed to fail. For chronic skin conditions, patient empowerment is a must. People should know and understand their condition and learn how to live with it, knowing how to contact their GP should their condition get worse or if there is an emergency.

1.3

Websites and Apps

We live in a world with a lot of information available. This accessibility can be good because it empowers the patient on his/her own skin condition; it can have the drawback of giving incorrect information or the worse scenario of a skin condition. GPs can help in reducing fear and anxiety

associated with skin problems by guiding the patient to a good website that will explain the diagnosis and treatment in simplistic terms (see Chap. 67 on useful patient resources and websites).

1.4

Patient Information Leaflets

As treatment plans can be complicated, and the patient will only remember a small amount of what you tell them, patient information leaflets (PILs) explaining the treatments are very useful (Chap. 66).

1.5

The GP Perspective

GPs have the rare opportunity to see skin diseases in their early stages. This is why the description of certain diseases found in classical textbooks are not always how they present in GP’s clinical practice. For example nodular BCCs (basal cell carcinoma) do not always present as the classical testbook description of a pearly white ulcerated nodule with raised rolled edges. Many GPs, non-dermatologist hospital practitioners, pharmacists and nurses struggle with dermatology problems because of the lack of proper training in this area both at the undergraduate and postgraduate level. There is a lack of a simplified and accessible knowledge addressed to these professionals who are the first at attending a population with skin conditions. Managing basic concepts and simple skills will allow non dermatologist to deal correctly with a large number of skin problems. The need for properly trained GP’s becomes more imperative as the number of patients with skin problems increase (the population is living longer; elderlies tend to have more skin diseases) and the number of dermatologists stays stagnant (even reduced by the outflow into cosmetic medicine). A properly trained GP will not refer patients with relatively simple skin problems to dermatology OPD (outpatient department).  This will

1  Dermatology in Primary Care

reduce overcrowding, long waiting times and lack of time for the dermatologists to get involved in training in dermatology in primary care. Teledermatology will further help GP’s in getting advice on cases where there is no certainty. The diagnosis and treatment of most dermatology problems rarely requires complicated or expensive imaging modalities such as CT scans or operating theatres with general anaesthesia. Treatment usually involves simple topical or oral treatments and many lumps and bumps can easily be excised or removed with basic surgical skills that are well within the scope of many GPs once the correct diagnosis is confirmed. But simplicity comes from experience. Even treating a viral wart requires proper training and equipment.

1.6

Primary Care Dermatology

Dermatology in primary care can be very different from that seen in hospital dermatology departments [8]. In primary care diseases are often seen at an early stage when the clinical signs are vague and ill-defined. Patients may have overlap of more than one skin problem (e.g. acne and rosacea or psoriasis and atopic eczema) (Fig. 1.1). The clinical features may be altered by the patient’s own interventions (self medications, scratching, etc.). Others patients have chronic skin problems that are unresponsive or only partially controlled with hospital treatments. It is important to realise that while the skin specialist knows more about skin diseases, the GP has the advantage of knowing more about the patient ! GPs are ideally suited to manage patients with simple straight forward skin diseases as they can manage the patient holistically, dealing not only with the physical problems but also the psychological and social aspects of their skin problems. It is vital that skin problems are not dismissed as trivial or unimportant by the doctor. It is important to show empathy and understanding of the distress that skin problem can cause to

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Fig. 1.1  Atopic eczema and psoriasis overlap in a 16 year old

the patient. Primary care is probably the most appropriate place for chronic disease management and this is true for many common mild to moderate chronic dermatology problems. GPs should try to empower patients with chronic skin problems to manage at least some parts of their skin problem themselves. Nowadays, apps can help patients to manage their treatments, get advice on changing moles, etc. Some skin problems may involve other organ systems (atopic children may have asthma and allergic rhinitis as well as eczema) and the GP can manage all aspects of the illness rather than just the skin component. Also many skin conditions can have associated underlying pathology (e.g. diabetes, arthritis, depression, etc.) and GPs can manage the skin diseases holistically, dealing with all the underlying ailments as well as the skin problem. Nurses, pharmacists and GPs are ideally placed to promote skin wellbeing by applying health promotion and disease prevention strategies appropriately, including sun protection, occupational health advice and hand care. This book will hopefully make dermatological knowledge for the most common skin conditions accessible and practical in a simplified manner.

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References 1. Schofield J, Grindlay D, Williams H.  Skin conditions in the UK: a health care needs assessment skin conditions in the UK.  Centre of Evidence Based Dermatology, University of Nottingham; 2010. https://www.nottingham.ac.uk/research/groups/cebd/ documents/hcnaskinconditionsuk2009.pdf. Accessed 3 July 2014. 2. Tucker R, Duffy J. The role of the community pharmacist in the management of skin problems. J Pharma Care Health Syst. 2014;1:1. 3. Williams HC.  Increasing demand for dermatological services: how much is needed? J R Coll Phys. 1997;31:261–2. 4. Health and Safety Commission. Annual Report 1991– 92. London: HMSO; 1992.

D. Buckley 5. Royal College of General Practitioners. Training in dermatology for general practice. Morbidity statistics from general practice. Fourth National Study 1991–2. London: RCGP; 1995. 6. Von Hospenthal T.  Lessons for the NHS: commissioning a dermatology service BASED ON CASE STUDIES FROM ENGLAND. British Association of Dermatologists Clinical Services Manager July 2013. https://www.bad.org.uk/shared/get-­file.ashx?itemtyp e=document&id=1009 7. Principles of dermatological practice. The prevalence of skin diseases DermNet NZ.  All about the skin. https://www.dermnetnz.org/cme/principles/the-­ prevalence-­of-­skin-­diseases-­cme/. Accessed 15 Mar 2019. 8. Wilmer EN, et al. Most common dermatologic conditions encountered by dermatologists and nondermatologists. Cutis. 2014;94(6):285–92.

2

History Taking and Examination David Buckley

Key Points • It is important to assess the patients’ ideas and concerns about their complaint and their expectations regarding treatment. • The distribution of a rash may help clinch the clinical diagnosis. • When examining scaly or scabby lesions it is advisable to remove the scale or scab to reveal what is underneath. • In dermatology, taking the history from the patient may be carried out during or after the examination in order to save time and be more focused with questioning. • Absolute recognition of a rash or a lesion on the initial consultation is desirable although not essential once the doctor can rule out more serious pathology such as a melanoma or a serious skin infection.

2.1

Introduction

The vast majority of skin problems in primary care can be diagnosed by taking a careful history and carrying out a thorough physical examination. A full body skin examination including the scalp, nails, genitalia and peri-anal skin may

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland e-mail: [email protected]

need to be carried out looking for clues to the diagnosis or signs of skin conditions including cancer or pre cancer on other parts of the body.

2.2

History Taking

Diagnosis in dermatology, like most other specialities, involves careful history taking (Table 2.1) and a thorough physical examination. In dermatolTable 2.1  History taking in dermatology • History of the presenting complaint    – Onset, duration, periodicity    – Site of onset, spread, distribution    – Aggravating or relieving factors • Previous history and family history    – Skin problems    – General medical problems • Medications    – Oral or topical    – Prescribed and non-prescribed • Allergies   – To drugs    – To food, clothing, footwear, jewellery, toiletries or cosmetics • Occupational    – Current and past • Sports and hobbies • Animal contacts    – Including birds, fish and rodents • Human contacts • Foreign travel • Recent stress • Alcohol intake

© Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_2

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ogy, taking the history from the patient may be carried out during or after the examination in order to save time and be more focused with questioning. It is important to elicit the timing of the rash, where it first appeared, how it spread and its response to various over the counter or prescribed treatments. Sometimes the patient may have no rash on the day they visit the doctor and the history may be the only way to try to make the diagnosis. A recurrent vesicular eruption that always comes up in the same area and heals without scaring is almost certainly due to herpes simplex (“Cold Sores”) but could be due to a fixed drug eruption which is very rare. A hive or nettle sting like itchy rash that can come a go on various parts of the body and does not stay in any one area for more than 12–24 hours is almost certainly due to urticaria. Symptoms such as itch (=allergy), pain (=infection), oozing or bleeding is also important to document. Even when the diagnosis is obvious (e.g. acne or psoriasis) a careful history is still important to identify any precipitating or aggravating factors and to assess the patients’ ideas and concerns about their complaint and their expectations regarding treatment (“ICE”). Sometimes mild disease, (e.g. acne,) may have to be treated more aggressively if the condition is having a severe impact on the patient’s quality of life. Questionnaires such as the “Dermatology Life Quality Index” can help identify how the skin problem is affecting the patient’s quality of life [1]. It is also important to note that sometimes patients have an obvious skin condition (like acne) but their motive for consultation is a different problem. Wait for the patient to tell you what is bothering him/her before jumping to conclusions. A dietary history is sometimes necessary as excess sugar, fats, caffeine or alcohol may precipitate or aggravate certain skin problems. A dietary history may also reveal the possibility of an underlying food allergy or a dietary deficiency (e.g. calcium, iron, folic acid, etc.). A drug history (oral or topical, prescribed or over the counter) is also important particularly when faced with an unusual rash. Occupations, hobbies, pets, foreign travel, contact with others with similar symptoms, underlying medical problems (e.g. diabetes, SLE, etc.) and family history may also be relevant.

2.3

Physical Examination

A thorough physical examination is important when dealing with difficult to diagnose rashes as important clues to the diagnosis may be found in hidden areas, such as the scalp, the groin or between the toes or in the nails. Good light (daylight if possible), magnification and a warm room are helpful. Make up should be removed when examining the face. A complete head to toe examination is necessary especially when the diagnosis is not clear as the distribution of a rash may help clinch the clinical diagnosis. When examining a rash, first study the form of the individual lesions, then the pattern of the lesions on the body and their spatial relation to each other. Many rashes can look similar when you examine the individual lesions but they often have distinctive patterns which will help with the diagnosis (e.g.: psoriasis usually occurs on the backs of the elbows and front of the knees while eczema usually has the opposite pattern) (Fig.  2.1). A unilateral red scaly rash is more likely to be fungal. A persistent isolated scaly rash may be due to fungal infection, neuro-­ dermatitis (lichen simplex chronicus) or a skin cancer or pre-cancer such as actinic keratosis, Bowens disease or a superficial spreading basal cell carcinoma. Photosensitive reactions will be found in sun exposed areas. A full skin examination is also necessary when dealing with patients with skin cancer or suspicious moles. In addition, by examining all the skin you may also find other significant skin, hair or nail pathology that the patient was not aware of. All patients should be offered a chaperone if examining intimate areas and this should be recorded in the notes, even if the patient declines. When examining all the skin, it is not necessary to ask the patient to strip completely. Get the patient to take off their top clothing (including their bra if necessary) and examine that area first. Then ask them to put back on their top clothes before removing their lower clothes (including their underwear if necessary). By retaining at least half of their clothing they will feel less exposed and vulnerable. Great care and sensitiv-

2  History Taking and Examination

9

Fig. 2.1  Distribution of various common rashes

ity is required when examining children who can be very easily embarrassed. Also, young adults may want a chaperone before examining intimate areas. Very often, explaining why you need to examine these areas can alleviate fears and embarrassment. A magnifying light is extremely

useful when examining and treating small lesions. Dermoscopy (skin microscopy) is invaluable when diagnosing suspicious pigmented lesions and can also be useful in diagnosing some non-­ pigmented lesions, scabies and scalp problems (Fig. 2.2).

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Fig. 2.2  How to examine the skin

When examining scaly or scabby lesions it is advisable to remove the scale or scab to reveal what is underneath (e.g. a nodule, superficial ulceration, an erythematous macular area or perhaps normal skin) which will help in making the diagnosis (Figs. 2.3 and 2.4). Palpating a lesion (e.g. the characteristic pebbly feel of a dermatofibroma), stretching the skin around the lesion to

delineate the borders (see Fig. 45.20; Chap. 45) or feeling a rash, (e.g. the typical feel of keratosis pilaris, psoriasis or actinic keratosis) can often help in the diagnosis and also reassure the patient that it is not contagious. If the lesion is bleeding or weeping, gloves must be worn. Careful hand washing or using hand sanitizers before and after examining all patients is important, especially

2  History Taking and Examination

Fig. 2.3  SCC (Squamous cell carcinoma) on the tip of the ear which is more obvious after removing the scab

Fig. 2.4  BCC L upper cheek

when palpating the skin. Do this in front of the patient so they can observe the importance placed on hygene. All suspicious lesions should be measured (largest and opposite diameter and sometimes the amount of elevation) in millimetres and an accurate description of the location of the lesion should be made. A surface anatomy mapper that describes a location on the body can be very useful (e.g. http://anatomymapper.com). Photos are also an effective way to record the size and location of a lesion and observe changes over time and useful when referring a patient as they may speed up the referral process if the receiving doctor realises how severe the rash or lesion is. A ruler may need to be included in the photo to give the lesion’s perspective. The severity of a skin problem can be scored as mild, moderate or severe. As this three point scoring system can be limited, add two more levels (“mild to moderate” and “moderate to severe”). It is surprising how often the doctor and patient agree on the level of severity of their skin

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problem. If the patient is complaining of a “severe” skin problem but the doctor is only seeing mild disease, it should alert you to the possibility of underlying psychological problems (e.g. body dysmorphic syndrome). On follow up, after initiating treatment, it is helpful to ask the patient if their skin condition is the “same, better or worse” than their last visit. Sometimes it is useful to score the improvement (e.g. 25%, 50%, 75% or 90% better). Becoming skilful in dermatology depends on having a good knowledge of the natural history of common skin diseases and an accurate visual memory of previous cases. Discussing cases with colleagues within the practice may help, as they may recall seeing a similar case previously. Published and “on line” dermatology atlases can be a very useful way of learning the appearance of common rashes and lesions. Artificial intelligence (AI) is already available to aid diagnosis using algorithms and photos in dermoscopy and will become more available in the future [2]. Absolute recognition of a rash or a lesion is desirable, although not essential, on the initial consultation once the doctor can rule out more serious pathology such as a melanoma or a serious skin infection. Reviewing the patient after a few weeks may be helpful as the classical, clinical signs of a disease may become more obvious with time. A good atlas of dermatology or a good website with lots of pictures is a significant help when struggling with a diagnosis and when trying to explain the nature of a problem to a patient (see Chap. 67  =  useful resources + bibliography). “Google images” is a very quick way to find pictures of various skin rashes or lesions to compare to what the patient has or to explain to the patient what the rash or lesion can look like on other patients. However, “Google images” are not always correctly filtered according to diagnosis and the photos may scare some patients. The patient should be encouraged to photograph their rash or lesion over time to monitor the progress and they may help clinch the diagnosis in cases where the rash is not present or florid on the day and time the patient presents as in urticaria.

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2.4

Conclusion

Taking a proper history in dermatology not only helps make the diagnosis but will also illicit how the patient feels about their skin problem and what they expect from treatment. A thorough physical examination of the skin may help make a diagnosis and not infrequently can show up other dermatology problems that the patient may not have been aware of.

References 1. Lewis V, Finlay AY. 10 Years experience of the dermatology life quality index (DLQI). J Investig Dermatol Symp Proc. 2004;9:169–80. https://doi. org/10.1111/j.1087-­0024.2004.09113.x 2. Haenssle HA, et  al. Man against machine: diagnostic performance of a deep learning convolutional neural network for dermoscopic melanoma recognition in comparison to 58 dermatologists Ann Oncol. mdy166. https://doi.org/10.1093/annonc/mdy166. Published: 28 May 2018.

3

Investigations and Treatment in Primary Care Dermatology David Buckley

Key Points  • Photos of the rash or lesion, which the patient may have taken themselves on their phone or home camera, can often help in making a diagnosis or assess severity. • Skin scrapings for fungal stain and culture are sometimes necessary to rule out a fungal infection before starting a potent topical steroid in a vague, non-specific, asymmetrical rash. • Biopsying vague, non-specific rashes is often unhelpful unless looking for specific conditions that have characteristic histological features such as lupus or lichen planus. • Non-prescription or over the counter products can often be as or more important than prescription items when treating skin disease.

3.1

Introduction

If a careful history and a thorough physical examination does not make a confident clinical diagnosis the doctor may need to carry out various investigations such as blood analysis, skin scrapings, nail clippings or a skin biopsy to help

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland e-mail: [email protected]

make the diagnosis. All potentially malignant skin conditions should have a biopsy to confirm the diagnosis histologically. It should be made clear to patients when treating skin conditions whether we are trying to cure the condition or merely control the symptoms and improve the appearance of the skin.

3.2

Investigations

Most skin problems can be diagnosed clinically with a detailed history and a thorough physical examination using good light, magnification and a dermoscope if available. Special investigations may sometimes be necessary to confirm a clinical diagnosis or to rule out more serious pathology. Dermoscopy is a very useful tool for diagnosing not only suspicious pigmented lesions but also a number of common benign and malignant lesions that have characteristic dermoscopy features such as melanoma, BCC, seborrhoeic keratosis and scabies [1]. Skin scrapings for fungal stain and culture are sometimes necessary to rule out a fungal infection before starting a potent topical steroid in a vague, non-specific, asymmetrical rash (Fig. 3.1). With a little practice and experience a GP should be able to examine skin under a Wood’s lamp and scrapings under a microscope to reveal fungal elements or scabies (mites or eggs). Special haematological, biochemical, histological or micro-

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lem as a result of spurious “allergy tests” carried out in health food shops or by alternative practitioners [2] (see Chap. 21).

3.3

Fig. 3.1  Skin scraping to isolate the fungus in Tinea manuum

biological tests can be performed by taking specimens in the surgery and sending them to the local hospital. Biopsying vague, non-specific rashes is often unhelpful unless you are looking for a specific diagnosis that has characteristic histological features such as lupus or dermatitis herpeitiformis. It is best to send your histology specimens to a pathologist who has a special interest in dermato-histopathology and with as much clinical details as possible. The pathologist will need to know the age of the patient (date of birth), the location of the biopsy and the type of biopsy (punch, shave, incision, excision, etc.) and a reasonable working and differential diagnosis. If you cannot do this, it might be better to refer the patient to a more knowledgeable colleague rather than taking a biopsy. Pathologists dislike getting a specimen with sparse clinical details such as “itchy rash” (see Chap. 57).The response will probably be “non specific chronic inflammation”. Other special investigations may be indicated, such as biopsies for immunofluorescence to assess blistering diseases or a jejuna biopsy for coeliac disease, but patients are usually referred for these tests. Allergy testing such as IgE and RAST test, skin prick testing, skin patch testing or exclusion diets are sometimes necessary to identify underlying allergies that may or may not be already suspected from the history. Allergy testing may also be necessary to exclude allergies such as food allergies that the patient or parents may falsely believe are responsible for their skin prob-

Treatment Approach

When treating dermatology patients it is very important to explain whether you are aiming to cure or simply control their problem. Give realistic expectations as to how long it will take for the treatment to work as, unlike other branches of medicine, with dermatology problems, everything is on the surface for the patient to see and monitor themselves. For example, psoriasis usually takes 6–12 weeks to improve and acne can take 3–6 months to clear. By not giving this information from the outset, the patient may give up their treatment too early or shop around for another opinion. Follow up is also important to monitor the success of the treatments and encourage the patient to continue with them. At follow up, it is helpful to try to quantify the improvement (if any) by a global assessment by the doctor and the patient (e.g. 25%, 50%, 75% of 90% improved). Photography can be very valuable. Take a good standardized picture previously consented by the patient anytime you feel it will help to monitor a skin condition. Some patients may over estimate the response to treatment or fail to admit that it is getting worse in an attempt to please the doctor. Asking the patient if the condition is “the same, better or worse” is more open ended and more likely to get an accurate response. If the patient is not responding to treatments it is important to check compliance and review the original diagnosis. My personal “rule of three” is that if a patient comes back three times with the same problem, it means that it is not improving. If this is the case, refer the patient on to another colleague with more experience in that area for their opinion; otherwise the patient may lose confidence and they will probably default on follow up and go elsewhere. In general, patients tend to appreciate when their doctors ask for a second opinion. It shows humility and capacity for team work.

3  Investigations and Treatment in Primary Care Dermatology

It is important to reassure patients that their rash is not infectious, disfiguring or cancerous (when it is not), as this will often be their biggest fear. It is also important to confidently inform the patient that you can treat their condition (either cure or improve the visual appearance of the condition) or at least reassure the patient that you can refer them to someone else who can help them. When treating patients, have a plan of action with a list of differential diagnoses and treatment options and record them in the original consultation. Should the patient not improve on follow up, then review to your original notes to establish what was thought on the first visit. A busy practitioner will not remember what they were thinking a month previously. My dad used to say: “Bad ink is better than a good memory”, write it down! Some dermatology problems may be temporarily improved on the day the patient visits you. Always ask the patient is the problem “average, good or a bad” on the day they present. Photos of the rash or lesion, which the patient may have taken themselves on their phone or home camera, can often help in making a diagnosis or assess severity. The clinical signs may be much different on a follow up visit so do not expect to always have to make a definitive diagnosis on the first visit. Many dermatological disorders are treated by topical agents. It is important that the doctor instructs the patient carefully on how to use these preparations, particularly potentially irritating creams and topical steroids (see Chaps. 62–64). The doctor should demonstrate exactly how much is to be applied, how often to apply it, in which way should it be applied (e.g. rub downwards) and on which part of the body the topical treatment should be applied. Otherwise, patients may under or over use their treatment, resulting in poor response or side effects. An old saying in dermatology is “if it is wet, dry it and if it is dry, wet it”. This is a little over simplistic but still has some merits. “Dry” skin is usually itchy and scaly and will almost always benefit from a good, safe, greasy moisturiser and avoidance of soaps and other irritants. Skin that is “wet” or weepy is usually very inflamed and may

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be infected. It will usually benefit from dampening down the inflammation with a simple cooling cream and/or a topical steroid cream and treating any infections with an appropriate topical or oral antibiotic. While prescription medications are often necessary when treating dermatology patients, the non-prescription or over the counter items can often be as important or more important, (e.g. moisturisers, soap substitutes, gloves, acne washes, non-comedogenic make-ups, etc.). Show the patient or parents what these products look like by having various tubes and pots in your clinic. It is helpful to demonstrate (either you or your assistant) how to apply the various products and give them estimation as to how long a tube or tube should last. Life style modification may also be necessary in order to alleviate the problem or prevent relapse (e.g. weight loss, alcohol reduction or avoidance, dietary restrictions, etc.). Patients may also need psychological help to manage scratching, squeezing or picking their rash or lesion. Some dermatology patients can have deep psychological problems such as body dysmorphic disorder, delusional infestation or dermatitis artefacta that may need psychiatric assessment (see Chap. 53).

3.4

Conclusion

Investigations in dermatology may be necessary to make a diagnosis or to reassure the patient that there is nothing more sinister underlying their skin complaint. Treatment does not always require prescription medication or skin surgery. Sometimes, simple over the counter treatment, lifestyle advice and reassurance may be all that is required.

References 1. Marghoob AA, Usatine RP, James N.  Dermoscopy for the family physician. Am Fam Physician. 2013;88(7):441–50. 2. Roberts S.  Challenging times for food allergy tests. Arch Dis Child. 2005;90:564–6.

4

Structure and Function of the Skin David Buckley

Key Points  • The skin is made up of three layers—the outer epidermis, the middle dermis and the deep subcutaneous fat layer. • If the physical, microbiological or chemical barrier function of the skin is compromised, it can lead to various local cutaneous or general systemic diseases. • Diseased skin, especially in exposed parts of the body, can lead to low self esteem, withdrawn behaviour and even unemployement.

4.1

Introduction

It is important to understand the structure and function of the skin as this will lead to a better understanding of how to diagnose various skin conditions and how to manage them. Treatments work better if we not only try to improve the appearance of the skin but also restore the function of the skin that may have been compromised by the skin problem.

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland e-mail: [email protected]

4.2

Structure and Function of the Skin

It is important to know the structure and function of the skin to understand how it can be affected in disease processes [1]. The skin is the largest and most visible organ in the body. Without it, life would not be possible. A burn of >40% of the body surface area can often be fatal. The skin consists of three layers (Fig. 4.1a, b). The epidermis is made up of a complex matrix of cells called keratinocytes, which produce a protein called keratin. The keratinocyte cells are stacked like a stone wall with keratin in between each cell like mortar in a stone wall. If the mortar is defective or absent, it will affect the skin barrier function. Recent studies have shown that many children with atopic eczema have a mutation in the gene which encodes filaggrin which is a key structural protein in the outermost layer of the epidermis and which binds keratinocytes together. This is why these children have a defective skin barrier and are susceptible to infections, allergens and irritants. The epidermis is constantly being replaced by new cells dividing at the basal layer. The old cells gradually die and fill up with hard keratin. As each cell dies it moves up towards the surface of the skin, to be shed or worn away. This production of cells at the base of the epidermis is

© Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_4

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18 Fig. 4.1 (a) Structure of the skin. SKIN© [matoomi]/123RF.COM Image ID: 85121693. Media Type: Vector. https://www.123rf.com/ photo_85121693_ human-anatomy-skinand-hair-diagramcomplexion-physiologysystem-medical-healthybeauty-cosmetic-mak. html?vti=njjzii1h3b bngxxosc-1-1 Copyright [email protected] (b) Epidermal layers of the skin. EPIDERMIS© [designua]/123RF.COM Image ID: . 35866489. Media Type: Vector. https://www.123rf.com/ photo_35866489_cellin-the-epidermis-layersof-epidermis-structureof-the-human-skin-.html ?vti=n1xflmnybo3764l 90e-1-12. Copyright [email protected]

a

b

carefully balanced with the loss of cells at the surface of the skin. If the rate of cell replacement is altered, a skin problem develops. For example, in psoriasis there is an abnormal build-up of cells being produced and pushed up from the base of the epidermis resulting in thick scaly skin.

The basal layer of the epidermis contains pigment producing cells called melanocytes. The epidermis is separated from the dermis by the basement membrane. The dermis contains the pilo-sebaceous units which consist of the hair follicle, oil (sebaceous) producing gland and the arrector pili muscle,

4  Structure and Function of the Skin

sweat (eccrine) and scent (apocrine) producing glands. Nerve endings and blood vessels are also found in the dermis. The dermis contains collagen and elastin which support the skin and give it suppleness and elasticity. With age these gradually deteriorate, causing the skin to sag and wrinkle. This process is accelerated by excessive exposure to ultra violet light. Despite claims by many cosmetic companies, there is little evidence that cosmetic creams or lotions can penetrate into the dermis and counteract the effects of ageing. The subcutaneous fat provides cushioning, thermal insulation and energy storage. It also has important function in hormone production.

4.3

Hair and Nails

Hair and nails are formed from dead keratin, so various commercial preparations advertised to strengthen or rebuild hair or nails are of questionable value. Plucking or shaving facial hair does not make it grow any faster, darker or thicker.

4.4

Function of the Skin

The skin has a number of vital functions (Table  4.1). Health care professionals often underestimate the importance of the skin, hair and nails in socio-sexual communication. This function is often enhanced by cosmetics, jewellery and perfumes. Diseased skin, especially in exposed parts of the body, can lead to low self esteem, withdrawn behaviour and even unemployment. In addition, chronic pain or itch can lead to insomnia, depression and suicide. If the

19 Table 4.1  Summary of the most important functions of the skin 1. Barrier—physical, thermal, antimicrobial, chemical and radiation barrier 2. Regulates body temperature—cools us when too hot and heats us when cold 3. Fluid balance—prevents loss of essential body fluids and excretes salt and other toxic substances with sweat 4. Mechanical support 5. Immunological function mediated by Langerhans cells-protects against microbes and allergins 6. Communication—sensory organ for touch, heat, cold and emotional sensations 7. Metabolic—vitamin D synthesis, steroid synthesis and storage of energy in the fat layer 8. Psycho-sexual function

physical, microbiological or chemical barrier function of the skin is compromised, it can lead to various local cutaneous or general systemic diseases.

4.5

Conclusion

The skin is the largest organ in the body in surface area and weight. It consists of three layers: the epidermis and the dermis and the subcutaneous fatty tissue. It has three main functions: protection, regulation and sensation. Wounds, rashes and tumours can affects varying levels of the skin from superficial to deep and can affect various functions of the skin.

Reference 1. Lai-Cheong JE, McGrath JA. Structure and function of skin, hair and nails. Medicine. 2009;37(5):223–6.

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Terminology in Dermatology David Buckley

Key Points • The name of many dermatological conditions are based on the Greek or Latin words to describe the physical appearance of the rash. • Many conditions in dermatology can have more than one name to describe the same thing. • Many rashes look similar when examined close up but they can have a predictable distribution which can help in the diagnosis.

5.1

Introduction

Dermatology, like any other specialist area such as computers or economics, has its own unique language and terminology. The name of many dermatological conditions are based on the Greek or Latin words to describe the physical appearance of the rash. Knowing the meaning of the words can make it easier to understand the underlying problem and remember the name [1]. For example, the term, lichen planus, was derived from the Greek word “leichen” meaning “tree moss” and the Latin word planus meaning “flat.” Lichen planus is a chronic inflammatory dermatosis of unknown origin that causes purple or vio-

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland e-mail: [email protected]

let papules and polygonal plaques that are shiny, flat-topped and firm on palpation. It can occur anywhere on the skin, mucous membranes, scalp or nails bur it often starts on the anterior wrists, ankles and lower back in adults. The word “pityriasis” was used by the physician Hippocrates in ancient Greece to describe the scruffy appearance of the skin that looked like it was covered by the fine bran of grain called “pityron”. “Versicolour” comes from the Latin word “versus”, or “vertere”, which means to turn or change color. Pityriasis versicolor is a common skin complaint in which fine, flaky, discoloured patches appear mainly on the chest and back mostly in young adults. It can cause hypo or hyperpigmentation that can vary according the seasons and the amount of ultraviolet light on the skin—hence the name = versicolor. To add to the confusion, many conditions in dermatology can have more than one name to describe the same thing. For example, a seborrhoeic keratosis is also known as a seborrhoeic wart or a basal cell papilloma. Actinic keratosis is also known as solar keratosis. Some conditions in dermatology may have a medical name which is often based on Latin or Greek terms but they may also have a common lay male name. Examples include dandruff (pityriasis capitis), ringworm (tinea corporis) or mole (melanocytic nevus). Descriptive terms are based on the colour, shape or texture of a lesion or rash. The spatial relationship of rashes or lesions are also important

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to describe, as various skin diseases have a characteristic distribution (isolated, clustered, satellite lesions, dermatomal, etc.). Many rashes look similar when examined close up but they can have a predictable pattern which can help in the diagnosis (e.g. psoriasis usually affects the backs of the elbows and front of the knees whereas atopic dermatitis usually has the opposite distribution).

5.2

Descriptive Terms [1]

• Lesion = a single area of altered skin. It may be solitary or multiple, isolated or diffused. • Rash = a widespread eruption of lesions. • Tumour = a solid mass of the skin or subcutaneous tissues. A tumour can be benign or malignant. • Dermatitis  =  inflammation of the skin; it is not a definitive diagnosis. There are many types of dermatitis. The term “dermatitis” and “eczema” mean the same thing. • Eruption  =  a break out or becoming visible (e.g. drug eruption). • Exanthem  =  another term for a rash (e.g. childhood viral exanthems). • Tinea  =  the name of a group of diseases caused by a fungus.

5.3

Colour

• Erythema/erythematous = redness secondary to vasodilation which blanches on pressure. • Telangectasia  =  persistant, visibly, dilated blood vessels on the skin or mucosal surface (“broken veins”). • Erythroderma  =  a skin condition which affects all or nearly all of the skin which is red all over (e.g. erythrodermic psoriasis). • Purpura = bleeding into the skin. If they are small they are called petechiae (small 10 mm.

• Pigmentation  =  any shade of brown, black, grey or blue resulting from the presence of melanin at different depths in the skin. • Non-pigmented = skin coloured, red, purple or white. • Hyperpigmentation = excessive colour in the skin that causes it to be darker than the normal background skin. • Hypo-pigmentation = loss of melanin causing the skin to be paler than the normal surrounding skin but not completely white. • Leukoderma = white skin (e.g. vitiligo). • Alba = comes from the Latin “albus” meaning white. • Leukonychia = whiteness of the nails.

5.4

 hape or Configuration of S Lesions

• Annular  =  lesion or rash in a circle or ring shaped such as ringworm or granuloma annulare (Fig. 5.1). • Discoid = a disc or coin shaped circular lesion (it is also called nummular). • Linear = in the shape of a straight line such as scratch marks or striae in pregnancy. • Polygonal = varied, non-geometrical shape. • Polymorphic or multiform = various different shapes. • Gyrate = a rash that is whirling in a circle. • Serpiginous = snake-like. • Poikiloderma = a mixture of areas of hypopigmentation, hyperpigmentation, telangiectasias and atrophy (e.g. Poikiloderma of Civatte).

Fig. 5.1  Anular rash of Granuloma annulare

5  Terminology in Dermatology

• Wheal (or weal) = papule or plaque like with oedematous elevation caused by swelling in the dermis with a smooth skin surface (e.g. urticaria). • Flare  =  erythema of the skin as a result of vasodilation often surrounding a wheal. • Target lesion  =  a series of concentric rings like a dartboard (e.g. erythema multiforme) also known as iris lesions. • Reticular = net-like lesions or rash (like the shape of a net curtain)

5.5

 exture or Morphology of T Skin Lesion and Rashes

• Macule  =  flat discoloration less than 1  cm (e.g. flat mole) (Fig. 5.2). Fig. 5.2  Macule and patch. SKIN LESION© [designua]/123RF.COM Image ID 50902545. Media Type : Vector. https://www.123rf.com/ profile_designua? page=1&word=skin+lesi on+&reverse_search_ mobile=&mediapo pup=50902545

Fig. 5.3  Papule and plaque. SKIN LESION© [designua]/123RF.COM Image ID 50902546. Media Type : Vector. https://www.123rf.com/ profile_designua? page=1&word=skin+lesi on+&reverse_search_ mobile=&media popup=50902546

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• Patch  =  flat discoloration greater than 1  cm (e.g. lentigo maligna) (Fig. 5.2). • Papule  =  palpable elevation less than 1  cm (e.g. acne spot) (Fig. 5.3). • Nodule or tumour = a solid, palpable elevation greater than 1  cm (e.g. acne nodule) (Fig. 5.4). • Plaque = a palpable lesion greater than 1 cm in diameter formed by the extension or coalescence of either papules or nodules (e.g. plaque psoriasis, granuloma anulare). Most plaques are elevated but a plaque can also be a thickened area without being visibly raised above the skin surface (Fig. 5.3). • Maculopapular = a raised lesion or rash that is flat on the top (e.g. plaques of psoriasis). • Cyst  =  epithelium lined cavity containing fluid or semi-solid material which may be

D. Buckley

24 Fig. 5.4  Nodule and papule. Note the volume difference. SKIN LESION© [designua]/123RF.COM Image ID 50902547. Media Type: Vector. https://www.123rf.com/ profile_designua? page=1&word=skin+ lesion+&reverse_ search_mobile=& mediapopup=50902547

Fig. 5.5  Sebaceous cyst. SKIN LESION© [designua]/ 123RF.COM Image ID 50159201. Media Type: Vector. https://www.123rf.com/portfolio/designua/10.html?medi apopup=50159201

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•

•

fluctuant (a fluid filled nodule such as in cystic acne) (Fig. 5.5). Abscess  =  a puss filled cyst  =  usually infected. Vesicle  =  a papule containing fluid less than 5 mm (e.g. herpes simplex) (Fig. 5.6). Bulla = a large vesicle more that 5 mm in diameter (e.g. bullous pemphigoid) (Figs. 5.6 and 5.7). Pustule  =  a vesicle filled with pus (neutrophils) which may be yellow or white. This does not always imply infection (e.g. acne pustule). Crust  =  dried sebum, pus, or blood usually mixed with epithelial and sometimes bacterial debris (also called eschar). Scale = increased dead cells stuck together on

the skin surface (also called hyperkeratosis). • Desquamation = skin shading off in scales. • Psoriasiform  =  large white or silver flakes like psoriasis. • Pityriasiform = fine, powdery scale. • Morbiliform = a rash that looks like the rash of measles (macular lesions that are red and are usually 2–10 mm in diameter but may be confluent in places). • Scarlatiniform = looks like the rash of scarlet fever (numerous small red papules widely distributed in the skin) • Lichenoid (Lichen)  =  scale tightly adherent to the skin surface like lichen on the rock at the seaside. • Lichenification = caused by chronic rubbing, which results in thickened skin with increased skin markings and lichenoid scale (Fig. 5.8). • Keratotic (Keratosis, hyperkeratosis) = horny scale with rough keratin (actinic keratosis). • Exfoliation = skin peeling. • Maceration = moist, peeling skin. • Dermatographism is the ability to write on skin  =  scratching the skin surface creates a wheel flare type reaction (e.g. urticaria). • Keloid  =  an exaggerated connective tissue response of injured skin that extends beyond the edge of the original wound. • Hypertrophic scar = an exaggerated connective tissue response of cut or incised skin that does not extend beyond the edge of the original wound.

5  Terminology in Dermatology

25

Fig. 5.6 Vesicles and bulla. SKIN LESION© [designua]/123RF.COM Image ID 50902548. Media Type: Vector. https://www.123rf.com/ portfolio/designua/ 10.html?mediapo pup=50902548

Fig. 5.7  Bullae in a patient with bullous pemphigoid

Fig. 5.8  Lichenification of the low back

5.6

• Soft, firm, hard, hot or cold. • Fluctuant = the movement within a swelling when it is examined by touch. It is a sign that the swelling contains fluid. • Sclerosis = Localised hardening of skin. • Mobile or fixed.

 eel, Form or Structure of a F Lesion

Papules may be: • Dome shaped = round on top like the dome of a mosque. • Filiform  =  thread-like or small protrusions like a filiform wart. • Flat topped • Pedunculated = with a stalk. • Sessile = without a stalk. • Umbilicated = with a central depression (e.g. molluscum contagiosum). • Verrucous = warty-like. Lesions or rashes may be: • Depressed = sunken under the skin. • Atrophic = thinned out. • Hypertrophic = thickened or raised up off the skin.

5.7

The Distribution of a Rash

Describes how rashes or lesions are scattered or spread throughout the skin (skin lesions may be isolated, solitary (single) or multiple. They can be localised or diffused. • Unilateral = a rash or lesion that is predominately on one side of the body. • Bilateral = affects both sides of the body or specific region. • Symmetrical  =  equal distribution on both sides of the body.

D. Buckley

26

• Truncal = rash or lesions mainly confined to the trunk but not affecting the limbs, head or neck. • Flexural  =  rash or lesion affecting the flexures (the bends or folds in skin such as the front of the elbows, back of the knees, around the neck in the axillae and groin creases). • Extensor surfaces  =  the opposite side to the flexured surfaces. • Acral  =  affecting the distal portions of the limbs, hands or feet. • Dermatomal = a rash or lesion that runs along a dermal distribution (e.g. shingles). • Follicular = lesions that arise out of hair follicles such as papules or pustules. They may be solitary or grouped into confluent plaques. • Herpetiformis = groups of small vesicles like herpes simplex or herpes zoster. • Köebner phenomenon (Köebnerisation) = refers to the tendency of a skin condition to affect areas that have been damaged due to injury such as scratching, laceration or burning. Common skin conditions that often demonstrate the Köebner phenomenon include psoriasis, lichen planus, vitiligo, warts and Darier disease (Fig. 5.9). • Fig.sensitivity = Rashes or lesions that occur only on the exposed areas such as the face, the “V” area of the neck and the dorsum of the hands and lower legs. • Seborrhoeic  =  a tendency towards oily skin (seborrhoea). The seborrhoeic area refers to those parts of the body that have a higher density of oil/sebum produced in glands such as the scalp, the eyebrows, the nasolabial folds, the post auricular area, over the sternum and the interscapular area of the back.

Fig. 5.9  Köbner (Koebner) phenomenon in a patient with psoriasis

Discrete = remains alone. Clustered = grouped together. Confluent = flowing together or merging Guttate  =  the Latin word for drops  =  i.e. looks like someone sprinkled the skin with drops. • Satellite = a rash or lesion surrounded by numerous, smaller lesions or rashes located adjacent to the main lesion or rash, e.g. candidiasis. • • • •

5.8

Secondary Skin Changes

These are usually as a result of scratching, picking or infection: • Lichenification  =  thickening and accentuation of the skin as a result of the chronic rubbing or scratching (e.g. lichen simplex chronicus) (Fig. 5.8). • Crusting = arises as a result of plasma exudating through an eroded epidermis. Crust is usually yellow or brown and may ooze. Epidermal crusts may contain blood which can make them look more red, purple or black. • Dystrophy = degeneration or abnormal morphology of the skin or nails. • Excoriation = scratching which removes epidermis and causes bleeding or oozing. They are often linear. • Prurigo = chronic skin disease with the eruption of pale, dome-shaped papules that itch severely and may be aggravated by picking and scratching. There can be many causes (e.g. purigo nodularis). • Erosion = loss of the surface of the skin in the upper most layers causing a shallow, moist or crusty ulcer (Fig. 5.10). • Fissure = a linear crack or break in the skin with abrupt side walls often due to excessive dryness (e.g. angular stomatisis, anal fissure) (Fig. 5.10). • Fungating = a large tumour that erupts like a mushroom or fungus. • Granulation tissue = formation of new capillaries and fibrous tissue in a healing wound that looks soft and red.

5  Terminology in Dermatology

27

Fig. 5.10 Fissure, ulcer, erosion. SKIN LESION© [designua]/123RF.COM Image ID 50902549. Media Type: Vector. https://www.123rf.com/ profile_designua ?page=1&word=erosion &reverse_search _mobile=&media popup=50902549

• Ulcer  =  circumscribed loss of tissue. Ulcers may be superficial, deep or full thickness (Fig. 5.10). They may be covered or hidden by a dark coloured crust called eschar. • Scar = permanent fibrotic changes that occur after healing of damaged to the dermis. Scars can be atrophic, hypertrophic, hypo or hyper-pigmented. • Granuloma = this is an histological term. When a pathologist sees chronic inflammation and giant cells in the skin as a result of certain infections (e.g. tuberculosis, leprosy) or inflammatory skin diseases such as granuloma annulare or sarcoidosis. • Granulomatous Diseases  =  those with the histological features of granuloma. • Nikolsky’s sign  =  is a skin finding in which the top layers of the skin slip away from the lower layers when slightly rubbed.

5.9

Nail Changes

• Onychogryphosis  =  thickening of the nail (not necessarily fungal in origin). • Nail dystrophy = disruption of the nail surface. • Lamellar dystrophy = splitting of the distal end of the nails in a horizontal plain (also known as onychoschizia).

• Onycholysis = lifting of the nail from the nail bed. • Pitting  =  small indentations in the nail as if they were damaged with a sharp needle (e.g. psoriasis, alopecia areata, eczema). • Koilonychia  =  spoon nails (e.g. with iron deficiency). • Clubbing = increased curvature in both planes (e.g. lung cancer, valvular heart disease). • Subungual = under the nail. • Periungual = around the nail. • Pterygium = a forward growth of the cuticle over the nail.

5.10 Conclusion There are many confusing and difficult terms used to describe lesions and rashes in dermatology. Many are derived from Greek or Latin. It is important to learn off these terms as they are the basic tools used to describe skin conditions and the descriptive terms are often used to make a named diagnosis.

Reference 1. Ways to describe skin lesions  – You Tube Video. https://www.youtube.com/watch?v=7pO0JaKZcts

6

Teledermatology Paola Pasquali

6.1

Introduction

Teledermatology (TD) is a new branch of medicine. In TD, the face to face visit is substituted by the analyses of images of the patient’s lesion or skin condition, the dermoscopic images and clinical relevant data which are all transferred via telecommunication technologies. Getting a second opinion can take minutes in comparison to costly transfer of the patient to the specialist’s office or waiting for an appointment at a hospital with long waiting lists [1]. Many dermatology consultations are for benign conditions that can be managed by the FP as long as the diagnosis is confirmed. For malignant lesions, TD can assist in getting an urgent referral. There are several reasons why many dermatology departments have long waiting lists: 1. Not sufficient numbers of dermatologists per 100,000 population 2. Mostly, because many benign skin conditions that do not require any medical treatment or could be treated effectively by the family physician (FP) are sent for consultation. These include skin tags, seborrheic keratosis and intradermal nevi.

P. Pasquali (*) Pius Hospital de Valls, Tarragona, Spain

Sometimes all that is needed is a second opinion to give reassurance on a diagnosis; in other cases, to make the diagnosis itself or even just to understand that the patient needs further and more specific examinations. Sometimes, TD helps in getting the FP to ask for certain lab or imaging tests before referring the patient, saving precious time for the patient.

6.2

 hat Can Be Sent? What W Should Not Be Sent?

Some conditions are more appropriate for TD, such as: • Single lesion • Tumors suspected to be malignant; in this case, a clinical image needs to be accompanied by a dermoscopic image. • Monitoring certain inflammatory conditions (like acne) Some conditions are less amenable for TD: • Multiple lesions (like in a multiple nevi patient) • Hair diseases because they tend to be difficult to photograph. A dermoscopic image is required to make a correct diagnosis in inflammatory diseases of the scalp.

© Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_6

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P. Pasquali

30

6.2.1 Types of TD Primary Teledermatology refers to direct communication between the patient and the health care professional (GP, nurse or dermatologist). It provides a direct service for initial diagnosis and referral [2]. Secondary Teledermatology refers to indirect communication between the patient and specialist. The patient (seeker) goes to a nurse/GP who then communicates with a specialist (provider) to receive advice. Other possible “intermediaries” are health insurance companies and healthcare institutions (nursing homes, emergency departments or pharmacies). Tertiary Teledermatology refers to “second” opinion among specialists (dermatologist) and a dermatologist with a particular specialization. It is a specialist-to-specialist consult. Patient Assisted. Patients communicate with a healthcare professional, usually for follow up or monitoring of skin conditions. It can be used for example for monitoring the response to treatment or for wound care. Direct to Consumer. Patients initiates the care by accessing a healthcare provider through personal devices (Smartphone, laptop or tablet apps).

6.3

Delivery Modalities

TD can be delivered in several modalities. 1. Real-Time (RT) Video Consultation (Live Interactive): employs live video conferencing. 2. Asynchronous Store-and-Forward (SAF). 3. Hybrid: Combines the above mentioned modalities. Real-Time TD is similar to a face to face visit but at a distance using live video. The advantage is that the specialist can ask questions directly to the patient or to the physician. Real-Time TD is time consuming and requires all parties to be available at the same time. It requires a good internet connection from both sides.

The most common type of TD is “Store-and-­ Forward” (SAF). The TD is sent by means of clinical and/or dermoscopic images, lab results or others, and the opinion is given later at a convenient time by the specialist. Clarifying questions cannot be asked immediately but could always be asked later.

6.4

Settings

The first TD was done to assist patients in rural or remote areas. With time, patients in large cities are also benefitting because transfer from one area to another in congested capitals can be time consuming and the difficulties to be seen promptly by a specialist are similar as for the patient in rural areas.

6.5

A Good Photograph

If diagnosis are going to be made from a photograph, this needs to be of good quality [3]. A good medical photograph needs as a minimum: 1. To be taken with the same light. Flash light is a light that has the same temperature and can be adjusted in intensity (in most high end cameras). Otherwise, the skin colour will appear in the photograph in different tones depending on the light source. Light changes by the minute and every light source casts its own hue on the scene: tungsten and fluorescent bulbs, day or afternoon light, cloudy or sunny days. Getting the correct colour is also referred as white balance (where white looks white). If you are not going to use a flash, you will need to adjust the white balance settings on your camera or mobile phone if you want your patient’s skin to look natural. 2. Position: get the patient in the standard anatomical position. To get the right picture, the patient will need to pose and so does the photographer. 3. Backdrop. Probably the most relevant aspect in a medical image is to remove any distur-

6 Teledermatology

bances from the background. Have a backdrop available (a piece of blue, green or black fabric) and put it behind the area you need to photograph. For point and shoot cameras, using a backdrop will help you get better focused images as the camera does not average the background focus with the skin lesion focus. Remove all distractions from the patient (glasses, clothes, make-up). For a tumor, send a picture of the lesion, a dermoscopic image and also a medium view to understand the size of the lesion in relation to the area where it is located. Most important of all, get written consent to take the picture, explaining why the photograph is needed and in what context it will be used. Send only through secure connections. Most patients will agree to be photographed as long as they are treated with respect and the use of the image is clear and safe. Include all the metadata/information necessary: age, sex, occupation, location of lesions, date of appearance, symptoms (itchy, painful, asymptomatic), chronic medication and medication used to treat the condition. It has been shown that melanoma sent via TD has a thinner Breslow thickness and as such, a better prognosis [4]. Another advantage is the educational effect. The FP receives a diagnosis in hours or maximum a few days when the image (mental and also digital image!) is still “fresh” in his mind. The association of image and diagnosis is part of an educational process which occurs through pattern recognition.

6.6

Actors

The FP is not always the one making the consultation. Nurses and patients may send consultations to FP. For bedridden patients this is in ideal situation because many unnecessary transfers are avoided. For people with reduced mobility and the confined elderly, this represents an enormous advantage. Besides saving time and money, some elderly patients can get upset when moved out of their familiar environment.

31

6.7

Patient Empowerment

Patients are fortunately taking more and more control of their health and disease. In the past all decisions were exclusively taken by the doctors. Today, a shared decision based on an holistic view of the patient’s life, understanding their personal needs and focusing on what could be beneficial, will result in a closer patient-doctor relationship. TD helps with this as it incorporates the speed of new communication technologies and platforms that are becoming more user friendly like websites, apps, or shared electronic health records.

6.8

Conclusion

TD is a new way of practising medicine. The advantages of TD include saving unnecessary travelling and peace of mind for the patients. Nurses and doctors will get an immediate answer for a complicated health issues. Not all skin conditions are amenable for TD consultation but for those that are, the advantage for the patient and the doctor is enormous. The Covid-19 pandemic has shown so. Artificial intelligence will help physicians and patients assess suspicious lesions and get second opinions faster and in a more precise way. The future is just beginning.

References 1. Armstrong AW, Wu J, Kovarik CL, Goldyne ME, Oh DH, McKoy KC, et  al. State of teledermatology programs in the United States. J Am Acad Dermatol. 2012;67(5):939–44. Available from https://linkinghub.elsevier.com/retrieve/pii/S0190962212002472 2. van der Heijden JP, de Keizer NF, Bos JD, Spuls PI, Witkamp L.  Teledermatology applied following patient selection by general practitioners in daily practice improves efficiency and quality of care at lower cost. Br J Dermatol. 2011;165:1058–65. 3. Pasquali P. Photography in dermatology. In: Baldi A, Pasquali P, Spugnini E, editors. Skin cancer: A practical approach. New York: Springer; 2014. 4. Moreno-Ramírez D, Ferrándiz L.  A 10 year history of teledermatolgy for skin cancer management. JAMA Dermatol. 2015;151(12):1289–90. https://doi. org/10.1001/jamadermatol.2015.3208.

Part II Adnexal Disease

7

A Stepwise Approach to the Management of Acne in Primary Care David Buckley

Key Points

What to Tell the Patient

• Acne is a chronic disease that can last months and years. • Comedones and micro comedones are the hallmark of acne and it is important to treat comedones at all stages of acne. • Acne originates in the pilosebaceous unit, occurring on areas of the body where these units are concentrated (face, neck, chest and back). • Topical anti-comedone treatments are effective to treat acne and also to prevent relapse. • Topical retinoids are a key class in acne management, having been shown to target microcomedomes, the precursor of all stages of acne lesions. • Most cases of acne should be treated first line with a topical retinoid or retinoid-like agent and a topical antimicrobial agent such as benzoyl peroxide. • Systemic therapy should be added to topical therapy in more severe cases. • Oral antibiotics should generally be used for only 6–12  weeks and to a maximum of 6 months—otherwise resistance may develop. • Oral antibiotics or oral hormone treatments should always be combined with suitable topical agents.

• Many teenagers and young adults will get acne at some stage in their life. • Acne occurs as a result of too much oil in the skin and blocked pores. • Acne is not an infection and is not caused by poor hygiene. • Everybody will outgrow their acne in time; however, it is hard to predict when exactly this will occur. • There are safe, effective treatments for all degrees of severity of acne. • Avoid picking skin lesions as it increases the risk of scaring (Fig. 7.1). • Avoid oily products on the skin such as oil-­ bases foundations or oily moisturisers. • Use oil free, non-comedogenic cosmetics if necessary. • All acne treatments are slow; it usually takes 6–12  weeks to see a good response and can sometimes cases take 3–6 months or more to clear acne. • Apply acne creams or gels all over the acne affected areas and not just onto the spots. • Some acne treatments can dry and irritate the skin when started. Use sparingly initially and use alternate days if necessary for the first week or two of use. Avoid scrubbing in the topical medication as it increases irritation.

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland e-mail: [email protected] © Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_7

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36

• Too much refined sugars or too much dairy products like whey protein powders can aggravate acne.

7.1

Introduction

Acne vulgaris should be considered a chronic disease. Like many other chronic diseases such as asthma or rheumatoid arthritis, treatment should be aimed at both settling the acute symptoms (papules, pustules, nodules, cysts, etc.) and preventing relapse. Acne is a very common, chronic, inflammatory skin condition. It occurs in 90% of teenagers and half of them continue to have acne as adults [1]. Acne is particularly cruel as it occurs on the worst part of the body (the face) at the worst time in a person’s life (teens and young adult). 20% of young people have moderate to severe acne [2] (Fig. 7.2). Severe acne can have long lasting

physical and psychosocial effects [3, 4]. The reduction in quality of life has been estimated to be as great as that associated with epilepsy, asthma, diabetes, or arthritis [5]. Acne can be associated with low self-esteem, depression and anxiety. Bulling of acne patients is not uncommon. Many youngsters with acne feel rejected and develop low self esteem. More than 2  in 5 teenagers (44%) who have had acne have avoided having their photo taken on social media because of acne and 34% of teens with acne avoid video chatting [6]. Severe acne or picking acne can lead to permanent acne scars (Fig. 7.3a, b). When treating acne, regardless of the severity, it is important to reassure the patient that acne can be controlled, although results may take 6–12 weeks and sometimes up to 6 months in more difficult cases. It is also important to explain that the treatments do not cure acne (except oral isotretinoin) and that they will need ongoing maintenance topical treatment when their acne has been brought under control so as to prevent relapse.

7.2

Fig. 7.1  Picker’s acne in a 17 year old

Fig. 7.2  Nodulocystic acne pre-oral isotretinoin in a 19-year-old patient

Clinical Features and Diagnosis

Acne is a disease of the pilosebaceous units which are found in high numbers in the face, chest and back. The usual clinical features are oily skin with open and closed comedones (blackheads and whiteheads) (Fig. 7.4a, b) (Fig.  7.5). These features are known as non-­inflammatory and may be all that is found in mild disease. Comedones may be large and obvious or tiny and only visible with a magnifying lense (microcomedones). More moderate acne will have signs of inflammation with papules and pustules distribute on the face, neck, chest or back (Fig. 7.6). More severe acne may have nodules and cysts which may result in acne scaring (Table 7.1) (Fig. 7.7). When the sebaceous content of the overgrown sebaceous gland is exposed to air, it gets oxidated, blackens and it is called a blackhead. When the gland is closed by skin, the sebaceous content maintains its color and it is called a whitehead.

7  A Stepwise Approach to the Management of Acne in Primary Care

a

37

b

Fig. 7.3  Permanent acne scars (a) Acne scars before microneedling; (b) same patient after 4 sessions of microneedling using the dermapen

When treating a patient with acne, it is important to know: • When did it first appeared? • Who has suffered from acne in the family and how severe was it? • What medication has been used? What has worked and what has not? • An assessment of the impact of the acne on the patient’s quality of life. Mild acne in someone who is very upset with it may require more aggressive treatment. • Understand the patients expectations • Ask about their habits (likes to use make up, the use of sun or sunbeds, alcohol, diet, sports, body building, picking, etc.) It is important to ask all questions and make visual contact with the adolescent patient. Parents have to be present but can sometimes take control and make decisions on the patient’s behalf (“How should he use it? How do we apply the medication?). By talking directly to the patient, he/she will feel part of the decision process and be more likely to follow instructions. Do not treat adolescents like children.

The non inflammatory and inflammatory features of acne may be found in certain patterns on the face, chest and back (e.g. T-zone, muzzle area, jaw line and neck, etc.). Some patients may only begin to develop features of acne in their 20s (adult onset acne) and some patients can have persistent acne into their 30s, 40s or 50s (Fig. 7.8). Acne is diagnosed clinically. There is no definitive diagnostic test.

7.3

Differential Diagnosis

Classical acne is easy to diagnose. Other conditions can cause papulopustular rashes on the face such as rosacea, peri-oral dermatitis, folliculitis, pseudofolliculitis barbae, a fungal infection, or pyoderma faciale (see Chap. 18). However they do not have the classical hallmark of acne which is oily skin (Fig. 7.9) and comedones (Table 7.2).

7.4

Pathophysiology

There are four main mechanisms in the aetiology of acne:

38

a

b

Fig. 7.4 (a) Open comedones (blackheads) in a 15-yearold; (b) closed comedones in a 30-year-old female

Fig. 7.5  Acne features. Blue = blackhead (open comedone), Yellow = Whitehead (closed comedome), Red = papule, Purple= pustule, Pink = excoriation form picking

D. Buckley

(a) Excessive production of sebum (under hormonal control) (b) Follicular plugging causing micro-­ comedones and comedones. (c) Overgrowth of micro-organisms especially Cutibacterium acnes (C acnes, formerly Propionibacterium acnes) which causes releases of inflammatory cytokines (d) Inflammation causes the pylosebaceous unit wall to ruptures resulting in an intense foreign body like reaction which leads to further development of inflammatory lesions (papules, pustules, nodules, cysts). The problem with acne is that the end organ (the pilosebaceous unit) is very sensitive to the normal fluctuations of hormones that occur in adolescence and young adults leading to increased sebum production. This may be genetically determined. While it is clear hormones (especially androgens) play a major rose in aetiology of acne, almost all patients will have normal hormonal levels in their blood. The only exception is patients with Polycystic Ovary Syndrome (PCOS). Acne can be aggravated by various factors including hormonal (PCOS), greasy moisturisers or makeup (Fig. 7.10), drugs such as progesterone only pills and implants (“Implanon®”) or the progesterone containing IUD (“Mirena®”), lithium,

7  A Stepwise Approach to the Management of Acne in Primary Care

39

Fig. 7.7  Nodulocystic acne in a young adult pre-tetralycal + topical retinoid and benzoyl peroxide

Fig. 7.6  Acne with comedones, papules and pustules in an 11-year-old female Table 7.1  Investigators global assessment scale for acne • Clear: indicating no inflammatory or noninflammatory lesions; • Almost clear: rare noninflammatory lesions with no more than one papules/pustule; • Mild: some noninflammatory lesions, no more than a few papules/pustules but no nodules; • Moderate: up to many noninflammatory lesions, may have some inflammatory lesions, but no more than one small nodule; • Severe: up to many noninflammatory and inflammatory lesions, but no more than a few nodules. • Very severe: multiple nodules and cysts +/− scars

B12, topical or oral steroids, stress, picking and lack of exposure to sunshine. Dietary factors may affect acne to a small extent, particularly excess dairy (skimmed milk, cheese and yogurt) or refined (processed) carbohydrates (sweets, cakes and fizzy drinks) [7]. Body builders may develop

Fig. 7.8  Acne in a 44 -year-old woman with skin type V

acne or worsen their existing acne as a result of excess creatine and whey protein powers in their diet or from abusing testosterone or other anabolic steroids.

D. Buckley

40

Fig. 7.10  Comedonal acne from vaseline in a 16 year old male

Fig. 7.9  Oily acne in a 15-year-old patient prior to oral isotretinoin

Table 7.2 Differential diagnosis of papulopustular rashes on the face and/or trunk Acne vulgaris Rosacea Perioral dermatis Superficial (non gram negative) folliculitis Gran negative folliculitis Malassezia furfur folliculitis (usually on the trunk) Tinea barbae Chloracne (from occupational exposure to halogenated aromatic hydrocarbons) Multiple milia Pyoderma faciale (severe acneform eruption on the face in women) Acneform drug eruptions Adenoma sebaceum (angiofibromas- as seen in tuberous sclerosis)

7.5

Treatment

When faced with a patient with acne, some GPs immediately prescribe an oral antibiotic medication such as lymecycline or minocycline as it

takes little or no time to explain to the patient how to use these medications. While oral antibiotics will reduce the inflammatory component of acne (papules and pustules) they do nothing for the basic underlying problem which is too much oil in the skin which leads to blocked pores and comedones (blackheads and white-heads). If the oiliness of the skin and the comedomes are not treated then the patient will not respond adequately to treatment and will relapse quickly once the oral antibiotics are stopped or resistance to the antibiotic develops. In addition, there is concerns that the excessive use of antibiotics can adversely affect the patient’s microbiome and may contribute to the development of antibiotic resistant bacteria. It is important to understand the mode of action of various acne therapies (Table  7.3). Choose the most appropriate treatment for the particular type of acne and select logical combinations. This step up, step down approach will hopefully simplify the management of acne and the success of treatment (Fig. 7.11).

7.6

Topical Treatments

The simplest way to treat oily skin and comedomes is with topical treatments (with the exception of oral isotretinoin, which we will discuss later). Topical anti-comedonal treatments are difficult to use, as most cause dryness and sometimes redness and soreness of the skin, particularly if they are used incorrectly.

+

Salicylic acid wash

+

+

+

+

Azelaic acid (“Skinoren®”)

+

++

Topical retinoids

++

Benzoyl peroxide

+

++

Topical antibiotics

++

++

Oral antibiotics

+

High dose oestrogens and/or anti-androgens ++

++

++

++

Oral isotretinoin ++

Adapted from Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003 Jul;49(1 Suppl):S1–37

Mode of action Decrease sebum production Reduce follicular plugging Reduce Cuti-bacterium acnes Reduce inflammation

Table 7.3  Mode of action of various anti acne therapies

7  A Stepwise Approach to the Management of Acne in Primary Care 41

D. Buckley

42 Acne A. All Cases Use a salicylic acid wash; avoid oily products & no picking

B. Mild Continue A. & add in: Comedonal acne Topical retinoid Or Azelaic acid

Inflammatory acne BPO or topical antibiotics*

worse

C. Moderate Continue with A. and B. and add in oral treatments: - e.g. Anti-bacterials x 3-6 months (+/- Antiandrogens x 6-12 months in females)

worse

D. Severe Refer for ORAL ISOTRETINOIN

better

For mixed type acne use combinations of above

Cured

33% may relapse Topical retinoid = adapalene or isotretinoin BPO = benzoyl peroxide Oral antibacterial agents = lymecycline, minocycline, erythromycin or trimethoprim. Antiandrogens = “Dianette’’, OCP containing progestins with anti-androgenic properties (eg; drospirenone, chlormadinone acetate) or spironolactone. *Topical antibiotics should only be used for a maximum of 12 weeks

Fig. 7.11  A stepwise approach to acne

The first step in the ladder in managing all patients with acne is to use a good anti-acne wash. While a bar of ordinary soap will definitely help, specific anti-acne washes containing salicylic acid are more effective but also more d­ rying. Most patients with very oily skin will tolerate a wash containing 2% salicylic acid. Those with more sensitive skin may only be able to tolerate a 0.5% salicylic acid wash. Women should be advised not to over moisturise the acne affected areas and should only use oil free (“non-comedogenic”) moisturisers and make-ups. All patients should be advised to never scratch, squeeze or pick their spots. They should be recommended to have a healthy balanced diet and take plenty of fresh air and exercise. Sun protecting products should preferably in gel and never in oils. Excess heat, humidity and sunblocks can worsen acne (“tropical acne”). Patients with acne might have different type of lesions when examined but there tends to be one that predominates.

When patients have predominantly comedones (blackheads and whiteheads = non inflammatory acne) it is best to use topical retinoids or retinoid like agents combined with 2% salicylic acid wash (Fig. 7.4a, b). Topical retinoids, such as isotretinoin (“Isotrex®”) or retinoid-­ like agents, such as adapalene (“Differin gel®”) are primarily anti-comedonal. Patients should be instructed to put these agents over the affected areas of the face and neck and not just on the individual spots. The patient needs to be instructed to apply them sparingly, especially at the start of treatment, until their skin gets used to the preparations, for instance on alternate nights. It is important to tell the patient that these products can take months rather than weeks to clear comedomes and to have a significant effect on acne. Topical retinoids should not be used in pregnancy. They have some skin lightning effects and may help if there is post-inflammatory hyper-­ pigmentation (PIH) in darker skin types (Fig. 7.8). Topical retinoids not only help clear up acne

7  A Stepwise Approach to the Management of Acne in Primary Care

43

lesions, they can also be used long term (months when used together and it might be more conveor years if necessary) to prevent relapse. nient to be used on alternate nights for the first When lesions are mostly inflammatory (pap- week or two till the skin becomes accustomed to ules and pustules), good results can be obtained the products. A light weight, non-greasy, non-­ by combining a salicylic acid wash with topical comedogenic moisturiser should be used in the benzoyl peroxide 5% (BPO) (Fig. 7.6). Benzoyl mornings if there is excessive dryness. Some are peroxide is predominantly an anti-bacterial agent commercially available and especially formuand is best used when there is mostly papules and lated for patient on oral acne treatment. pustules with not so many comedomes. Benzoyl Azelaic acid 20% (“Skinorin®”) is a useful peroxide 5% is quite drying and has to be used alternative when patients cannot tolerate topical sparingly, particularly at the start. New formula- retinoids or topical BPO as it has some comedotions such as “Acnecide 5%®” are less irritating lytic, antibacterial and anti-inflammatory effects than the older formulations such as “Quinoderm®” and is usually well tolerated. It also has some or “Panoxil®”. The 2.5% and 5% formulations weak skin pigment lightening effects if there is are as effective as the 10% formulation with any post inflammatory hyper-pigmentation. This much less drying and irritation. Benzoyl peroxide effect makes it ideal for treating patients with is an over the counter medication, which makes it darker skin types (Fitzpatrick type 4–6). It is cheaper than many other topical acne prepara- safer in pregnancy that topical retinoids. tions. It also comes in large tubes (60g) so it can Limit the use of topical antibiotics to a maxibe used on the chest and back, as well as on the mum of 3 months, as resistance is almost inevitaface, if necessary. It is safe in pregnancy. ble after this length of time. All doctors should use When using it on the neck or trunk you should as little topical or oral antibiotics as possible to warn patients that it can bleach coloured cloth- prevent the emergence of antibacterial resistance ing, so advise them to use white shirts, sheets, organisms and fortunately we now have plenty of pillow cases and towels. Patients (but especially alternatives to antibiotics when treating acne of all parents or carers) will appreciate being given this stages. It may not be too far away before we are piece of advice. Benzoyl peroxide is as effective not allowed treat acne with antibiotics. as topical antibiotics without the problem of Unlike oral antibiotics for acne, topical antibideveloping resistance so it can be used long term otics only have a weak anti-inflammatory effect. both to clear up the existing acne and to prevent Also, it is important to realise that topical antibiacne relapsing once under control. It also reduces otics have no effect on the oiliness of the skin or the carriage of antibiotic resistant micro-­ comedones. For this reason, it is probably better organisms and should be used in combination to combine topical antibiotics with a topical retiwith oral or topical antibiotic acne therapies to noid such as isotretinoin 0.05% + Erythromycin improve their long term efficacy. 2% (e.g. “Isotrexin®”) or a benzoyl peroxide For most cases of mild to moderate acne, combined with 10  mg clindamycin such as combining benzoyl peroxide with a topical “Duac®” for a maximum of 3 months. BPO used retinoid-­like agent can be very effective for both at the same time as a topical antibiotic many help treating acne and preventing relapse. However, reduce the development of resistance Once the the combined effect of a salicylic acid wash, ben- topical antibiotic is stopped, a topical retinoid zoyl peroxide in the morning and a topical reti- (together with benzoyl peroxide if there is any noid at night can be very drying and irritating. remaining inflammatory lesions) should be conThese products should be started individually tinued to prevent relapse. It is not good practice and sparingly and added in one week at a time. to use a topical and oral antibiotic together as this Combination products such as adapalene with will encourage antibiotic resistance. Never use benzoyl peroxide (“Epiduo®”) are convenient and topical or oral antibiotics as a monotherapy. improve compliance since it only needs to be Always combine them with BPO and a topical applied once a day. They are also more irritating retinoid if possible.

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7.7

Systemic Treatments

While topical therapies will work very well for mild or mild to moderate acne, for more troublesome acne, a systemic treatment may have to be added to these topical agents or introduced at the same time [8]. Oral antibiotics, such as lymecycline 300  mg (“Tetralysal®”) or doxycycline 100  mg daily should be used for at least 6–12 weeks and not more than 6 months as this will lead to resistance and loss of effect of the treatment. Oral antibiotics should always be user in conjunction with suitable topical agents such as a topical retinoid and topical benzoyl peroxide (Fig. 7.12a, b). The oral antibiotics that are used in acne have powerful anti-inflammatory effects which are

a

probably as important as their antibiotic effect when treating acne [9]. There adsorption is not affected by food or milk. To avoid oesophageal irritation and ulceration, adequate fluids (water) should be taken with tetracyclines. Doxycycline can cause photosensitivity and is probably best avoided in the summer months. Tetracyclines should be avoided in children less than 12  years old, in pregnancy and when breast feeding as they are associated with impaired bone growth, permanent discoloration of teeth and enamel hypoplasia in children (see section on infantile acne in Chap. 26). If the acne has not cleared after 6 months of oral antibiotics combined with good topical agents, then a different class of oral antibiotics could be tried such as doxycycline 100  mg daily or trimethoprim

b

Fig. 7.12 (a, b) Nodulocystic acne pre and post oral tetracyclines and topical adapaline +BPO combination in a 16 year old.

7  A Stepwise Approach to the Management of Acne in Primary Care

300 mg twice daily (these are off licence indications) [10] for 3–6 months. Trimethoprim can cause a severe generalized rash and all patients prescribed this drug for acne should be advised to stop it immediately if they develop a generalized rash. Erythromycin (500  mg BD for adults) for 3–6  months is useful if there is a risk of pregnancy and in children less than 12  years old although strains of C acnes resistant to erythromycin are becoming more common. Combining oral erythromycin with topical benzoyl peroxide may reduce the risk of developing resistant strains of C Acnes. Severe resistant cases not suitable for oral isotretinoin may respond to higher doses of oral antibiotics such as lymecycline 300 mg BD or doxycyclin 100 mg BD (off licence doses) combined with appropriate topical agents for 3–6  months [11]. Minocycline (“Minocin®”) is rarely used nowadays as it has more side effects than lymecycline or doxycycline (e.g. lupus and hepatitis) and is probably no more effective.

a

45

Large comedomes can be easily removed by a comedome extractor. Large fluid filled acne cysts can persist for weeks or months and can leave permanent scars. They should be aspirated and injected with intralesional steroids which usually make them resolve within a week or two (Fig. 7.7). Most patients with this type of acne will end up on oral isotretinoin (“Roaccutane®”) sooner or later! Oral Isotretinoin should be considered for patients with nodulocystic acne, acne conglobata (a severe form of nodulocystic acne with interconnecting abscesses, sinuses and scars), scaring acne or less severe acne not responding or relapsing after at least 6 months of a combination of topical and systemic treatments especially if the acne is having an adverse effect on the patients quality of life (see Chap. 8) (Fig. 7.13a, b). For very inflamed acne, some dermatologists use topical steroids (preferably combined with topical antibiotic, like “Diprogenta®” a combination of betamethasone and gentamycin), for the

b

Fig. 7.13 (a) Nodulocystic acne pre oral isotretinoin in a 17 year old, (b) Same patient after 6 months of oral isotretinoin

46

first 10–15 days of oral isotretinoin as inflammation could worsen at the start of a course of oral isotretinoin. It should be applied over the entire area. Sometimes even oral steroids for 7–10 days are used to reduce the expected worsening of inflamed lesions when starting oral isotretinoin. “Diprogenta®” is also indicated in cysts or pustules that are appearing and can be felt (painful). In such cases, it is used only on the lesion and for a few days. Larger cysts and nodules may need to be asperated and injected with steroid.

D. Buckley

skin friendly combined oral contraceptive pill (COP) that has a high dose of oestrogen and a progestogen with low androgenic potency (e.g. drospirenone, dienogest, nomegestrol or levonorgestrel) for ongoing contraception or other indications (e.g. “Yasmin®”, “Qlaira®”, “Zoely®”, “Logynon®”, etc.) (Figs. 7.14 and 7.15). Avoid 3rd generation OCP (e.g. “Marviol®”, “Minulet®”, “Cilest®”, etc.) as they have a twofold increased risk of venous thrombosis ­ compared to second or fourth generation OCPs. Ultra low dose oestrogen pills with only 20 mcg of oestrogen (e.g. “Yasminelle®”, “Microlite®”, 7.8 Acne in Women “Mercilon®”) should be avoided as they can make acne worse. Progesterone only contraceptives All the above mentioned treatments are suitable such as the mini pill, progesterone only implants for women. However, topical retinoids and oral (“Implanon®”) and the “Mirena®” IUD coil therapies such as tetracyclines and trimethoprim should be avoided in acne suffers as they can should be avoided in pregnancy. Oral erythromy- aggravate acne. cin and topical benzoyl peroxide are safe in preg“Dianette®” and other combined oral contranancy. If there are signs of an underlying ceptive pills should be avoided in heavy smokers hormonal imbalance (e.g. hirsutism, alopecia, and those with hypertension, hypercholesteraeobesity, infertility, menstrual problems, etc.) spe- mia, obesity or a history of venous thromboemcial investigations should be carried out (see bolism (VTE) (Table  7.4). All patients on these Chap. 9). pills need to be advised about the possibility of In younger, non smoking women, a combined VTE and be given the warning signs to look out pill containing 0.035 mg ethinylestradiol and the for. These OCPs should be combined with benantiandrogen, 2.0  mg cyproterone acetate zoyl peroxide topically. They usually need to be (“Dianette®”), can be helpful for acne, especially if continued for 6–12 months to be effective in acne she has other indications for the oral contraceptive (Fig. 7.16). Sometimes the OCP can be combined pill, such as for contraception, menstrual prob- with oral antibiotics and good topical agents, lems, hirsutism or polycystic ovarian syndrome although if the acne is bad enough to warrant this (PCOS). In addition, oral contraceptives are some- combination then the doctor should be considertimes added to oral isotretinoin (which is terato- ing oral isotretinoin. genic) to prevent an unwanted pregnancy. Spironolactone is sometimes used for refrac“Dianette®” is only licensed for moderate-to-­ tory acne in women especially if she is unsuitable severe acne which has failed to respond to alterna- or intolerant to oral contraceptive pills. It should tive treatments such as topical therapies and oral be started at a small dose (25 mg/day) and graduantibiotics as mentioned above. “Dianette®” can ally increased to an average of 100 mg/day. It can only be used in women of reproductive age and cause hyperkalemia, hypotension and menstrual should be stopped 3–4  cycles after the acne has abnormalities in some women. It is also teratrocleared (usually after 6–12 months). At this stage a genic especially in the third trimester. It can be woman could be switched over to a conventional, useful in women with PCOS.

7  A Stepwise Approach to the Management of Acne in Primary Care

47

12

PRESCRIBING GUIDE Oestrogen dosage Generation

20mcg

30mcg

35mcg

1.5mg

Phasic

1st Generation

No oestrogen NORIDAY

OVREENA

Synthetic progestogen 350mcg Norethisterone 150mcg Levonorgestrel

OVRANETTE

ANDROGENICITY

HIGH

VIOLITE 2nd Generation

MICROLITE

100mcg Levonorgestrel

LEONORE 30/75/125mcg Levonorgestrel

LOGYNON

MERCILON

MINULET

75mcg Gestodene

MARVIOL

150mcg Desogestrel

3rd Generation

AZALIA CERAZETTE CILEST

2.5mg Nomegestrol QLAIRA

4th Generation ELVINETTE YAZ

75mcg Desogestrel 250mcg Norgestimate

ZOELY

YASMINELLE

MEDIUM

ELVINA

LOW

2/3mcg Dienogest

3mg Drospirenone

YASMIN

PRESCRIBING GUIDE Fig. 7.14  Prescribing guide for the oral contraceptive pill in women with acne. Use a pill with high levels of oestrogen and low androgenicity (Table courtesy of Consilient Health)

7.9

Other Treatments

Other less common treatment options for acne include laser treatment (e.g. pulse dye laser), IPL (intense pulse light), chemical peels and photodynamic therapy.

7.10 Maintenance Treatment Regardless of which systemic agent is used for acne, it is important to remember to step down the treatment ladder to a topical retinoid maintenance treatment once the acne is under control to prevent relapse [8] (Fig.  7.11). Patients on oral therapies should be followed up every three months until the acne is under control to monitor response, check compliance and advise on main-

tenance treatment. It is also important to avoid oily makeup, creams and oily sun protecting products as these can provoke relapses.

7.11 Acne Scars Prevention of scars by aggressive treatment of the acne before it has had a chance to cause extensive or severe scaring is the best approach but sometimes patients present too late and already have scaring. While there is no treatment that will totally eradicate all the scars, there are some safe effective treatments what will improve the appearance of the scars depending on the type and severity such as microneedling (Fig. 7.3a, b), chemical peels, laser resurfacing, intralesional steroids, cryosurgery, fillers, subcision and punching out deep pitted scars.

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48

ACNE

ACNE

• • •

Generally mediated through progestogen More common side effect of 2nd generation pills – switch to a 4th generation pill If patient is on 4th generation pill & acne is persistent, increase oestrogen dose

CAUSE

ACTION

WHICH CONTRACEPTIVE?

Too much progestagenic potency

Try less progestagenic 4th generation brands 12

Elvina • Elvinette • Qlaira Yasmin • Yasminelle • Yaz Zoely

Too much androgenic potency

Try less androgenic brands containing desogestrel

Marviol • Mercilon

Too little oestrogen

Increase oestrogen to a higher dose

Minulet • Ovreena • Ovranette • Logynon • Cilest

Reproduced with the kind permission of Dr. Deirdre Lundy

Fig. 7.15  Prescribing guide for the oral contraceptive pill in women with acne

Table 7.4  Relative and absolute contraindications to the oral contraceptive pill (OCP) Age Weight

Smoking Hypertension

Heart disease High cholesterol Migraine

Diabetes

>35 in a smoker >51 in non-smoker with no other risk factors BMI >39 (WHO 4) BMI 30–39 (WHO 3) Note that measuring weight alone is not enough >40 per day (WHO 4) >15 per day WHO 3 at all ages!! >160/100 WHO 4 always >140/90 or on treatment WHO 3 Previous pre-eclampsia WHO 2 but WHO 3 if smoker Sometimes a contraindications. Check individual condition Always WHO 4 Family Hx in sibling or parent 35 WHO 4 Aura or focal symptoms WHO 4 If another WHO 2 present e.g. if smokes 10 IU/L, LH:FSH ratio increased (>2), with FSH normal) Oestradiol Sex hormone binding globulin (SHBG- reduced) Free Testosterone: (rased >2.5 nmol/l). If total testosterone is >5 nmol/L, exclude androgen-secreting tumours and congenital adrenal hyperplasia Random Blood Sugar HBA1C Thyroid function tests (TFT’s) Lipid Profile B12, folate, ferretin Prolactin Ultrasound of the ovaries and the adrenals (the presence of cysts does not prove PCOS and cysts do not have to be present to make the diagnosis of PCOS) Dehydroepiandrosterone sulphate (DHEAS) (for those with severe or rapidly progressive hyperandrogenism) 17-hydroxyprogesterone

Menstrual abnormalities

Fig. 9.2  Diagnosis of PCOC (2 out of 3)

Diagnosis of PCOS is based on the presence of any two of the following:

Bloods best taken during the first week after menstruation when not on any hormone treatment

a

• Polycystic ovaries on ultrasound or laparoscopy. • Menstrual irregularities (no periods or very occasional periods). • Clinical and/or biochemical evidence of androgen excess. (Rotterdam criteria): [3, 4] (see Fig. 9.2)

It is not essential to have cysts visible on ultrasound. Neither is a hormone analysis essential for diagnosis (Table  9.1). For instance, a woman with acne and/or hirsutism with oligimenorrhoea or amenorrhoea may be diagnosed as having PCOS. In this situation, neither an ultrasound nor

hormonal analysis needs to be done to confirm the diagnosis. An elevation of free testosterone in combination with a low sex hormone binding globulin (SHBG) is the most sensitive way to establish the presence of hyperandrogenism. If the total testosterone is normal (in the absence of the oral contraceptive pill), the diagnosis of PCOS is effectively ruled out. The patient needs to be off the OCP for at least 1 month before testing.

9  Polycystic Ovarian Syndrome (PCOS) Table 9.2  Differential diagnosis for PCOS Cushing’s disease Later onset congenital adrenal hyperplasia Androgen secreting tumours (ovary or adrenal) Ovarian hyperthecosis Table 9.3  Clues that there may be a more serious cause of androgen excess Abrupt onset of symptoms More severe disease Rapid progression Older age of onset Very high serum androgens (testosterone of >5 nmol/l) Free testosterone level more than double the normal Signs of virilisation (deep voice, cliteromegaly)

61

one. This stimulation is caused by excess LH produced by the anterior pituitary in response to increased gonadotrophin-releasing hormone (GnRH) or through high levels of insulin caused by insulin resistance. High insulin levels also suppress hepatic production of sex hormone-­binding globulin (SHBG) leading to higher levels of free circulating androgens, further adding to the hyperandrogenaemia. The underlying endocrine disturbance can exist in the absence of polycystic ovaries. Androgen levels may not correlate with clinical presentation and serum androgen levels may be normal [5].

9.5 9.3

Differential Diagnosis

Most women with clinical and/or biochemical evidence of androgen excess and menstrual irregularities will have PCOS.  However, other more sinister and serious factors can be responsible (Table 9.2). Some of the signs and symptoms of PCOS can be mimicked by androgen secreting tumours. This should be investigated if there is rapid onset of severe acne or hirsutism especially if these problems start in women over the age of 35 (Table 9.3). Deepening of the voice, cliteromegaly, total testosterone of >5 nmol/l or free testosterone level more than double the normal might also give clues to an underlying androgen secreting tumour of the ovary or adrenal gland. Measurement of dehydroepiandrosterone sulphate (DHEAS) should be included for those with severe or rapidly progressive hyperandrogenism to screen for a primary adrenal source, as DHEAS is a marker for adrenal hyperandrogenism. Raised 17 OH progesterone suggests late onset congenital adrenal hyperplasia.

9.4

Pathophysiology

Polycystic ovaries are thought to develop when ovaries are stimulated to produce excessive amounts of male hormones, particularly testoster-

Treatment

The first line treatment for all forms of PCOS is diet and exercise to reduce weight in the overweight. Specific treatments should be tailored to the patient’s major presenting complaints: Acne can persist into the thirties or forties in women with PCOS and often responds poorly to oral antibiotic and topical therapies. Acne in PCOS may require long term treatment to prevent relapse (see Chap. 7—acne in women). If a woman with PCOS and acne is overweight even a 5% drop in weight can help. Topical treatments such as topical retinoid, benzoyl peroxide or azelaic acid gel may help but most women with troublesome acne in PCOS will also need systemic treatment. While they may get some response from oral antibiotics, best results are obtained with hormonal treatments such as an oral contraceptive pill (OCP) with relatively high oestrogen dose and a progesterone with low androgenic action (e.g.:“Yasmin®” or “Cilest®”). “Dianette®” is a popular choice in women with PCOS, as it has a strong anti-androgen (cyproterone acetate) and 35 mcg of oestrogen (0.035 mg ethinylestradiol and 2.0 mg cyproterone acetate) which can be very effective. Results can be slow and can it can take 6 or 12 months before improvements are seen. Relapse is common when the treatment is stopped. “Dianette®” can only be used in women of reproductive age and should be avoided in smokers and those with hypertension, hypercholesteraemia, obesity or a history of

D. Buckley

62

venous thromboembolism (VTE) (see Chap. 7, Table  7.6). All patients on Dianette® need to be warned about the possibility of VTE and be given the warning signs to look out for. For women who cannot go on an OCP, non hormonal anti-androgens such as spironolactone combined with topical anti-acne treatments may help. Spironolactone acts as an anti-androgen and can help acne, androgenic alopecia and hirsutism. It is teratogenic so effective contraception should be used in women of child bearing age on this drug. It is usually started at a small dose (25 mg/day) and gradually increased to a maximum of 200 mg/day if required and tolerated. It can cause hyperkalemia and the Summary of Product Characteristics recommends that electrolytes should be monitored regularly. Recent research in JAMA suggests that monitoring electrolytes in healthy, young females is not necessary [6]. Some women with more resistant or severe acne may require oral isotretinoin but the relapse rate is higher in women with PCOS (see Chap. 8). Hirsutism is defined as excessive terminal hair (long, coarse and pigmented) that grows in a male pattern (beard area, lower abdomen and chest) and is more common in women with PCOS (Fig. 9.1a). While traditional methods such as bleaching, plucking, shaving or waxing may help and are safe, many women request a more specific treatment such as the oral contraceptive pill. “Yasmen®” (ethinyl oestradiol 30 + drospirenone) and “Yasminelle®” (ethinyl oestradiol 20 + drospirenone) arrest progression but do not reverse hirsutism. “Dianette®” (ethinyl oestradiol 35 + cyproterone 2 mg) on the other hand gives substantial reduction of hirsutism. Relapse is almost invariable when stopped, therefore these treatments may need to be taken over a prolonged period. Eflornithine 11.5% cream twice a day (“Vaniqa®”) can slow down hair growth but can be slow to work. If there is no improvement after 2 or 3  months the treatment should be stopped. Laser or IPL hair removal can be helpful in women with dark hair and light skin but the success rate is limited in women with PCOS. Laser hair removal should be done after hormonal treatment, on the residual hair and not

in patients that have not controlled their excess androgen levels (see Chap. 40). Female pattern alopecia (diffuse, non-­ scarring hair loss that presents with prominent thinning of frontal, central, parietal scalp hair) or sometimes male pattern (androgenic) alopecia can occur in approximately 22% of women with PCOS [7] (Fig. 9.1b). “Dianette®” or an OCP with low androgenicity are less effective against alopecia than against acne and hirsutism, but will give some improvement of alopecia in 30% of patients. Topical minoxidil (“Regaine®”) gives medium regrowth in 15% of patients. Spironolactone or hair transplant may also have to be considered (see Chap. 40). PCOS is linked with the metabolic syndrome and hyperinsulemia. 10% will go on to develop diabetes at some stage, particularly if they are overweight or if there is a positive family history of diabetes. There is also an increased incidence of abnormal lipid profile in women with PCOS.  Annual fasting blood sugar and lipids should tested, especially in the overweight or those with a family history suggesting increased risk of cardiovascular disease. If there is ologomenorrhoea or amenorrhoea, women should consider the oral contraceptive pill or the “Mirena®” IUD to give endometrial protection and reduce the risk of endometrial cancer in later life. Fertility issues, if they arise, are best dealt with by a gynaecologist. Clomiphene can induce ovulation in 75–80% of women but there is a risk of multiple pregnancies. Weight loss and metformin may also improve the chances of conceiving [8].

9.6

Conclusion

PCOS is a common and debilitating condition which mainly affects young women. Early diagnosis and correction of any weight problems are key to successful management. Specific treatments can be targeted towards the primary presenting features such as, dermatology (acne, hirsutism, and alopecia), gynaecology (menstrual irregularities or fertility issues) or metabolic dysfunction.

9  Polycystic Ovarian Syndrome (PCOS)

Patient information resource: “Verity” is a self-help group for women with polycystic ovary syndrome (PCOS). See their website at: www. verity-pcos.org.uk.

References 1. Teede H, Deeks A, Moran L.  Polycystic ovary syndrome: a complex condition with psychological, reproductive and metabolic manifestations that impacts on health across the lifespan. BMC Med. 2010;8:41. https://doi.org/10.1186/1741-7015-8-41. 2. Polycystic ovary syndrome: what it means for your long-term health; Royal College of Obstetricians and Gynaecologists, Guidance Information – revised 2009. 3. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19–25.

63 4. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, authors. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81:19–25. 5. Balen A.  The pathophysiology of polycystic ovary syndrome: trying to understand PCOS and its endocrinology. Best Pract Res Clin Obstet Gynaecol. 2004;18(5):685–706. 6. Plovanich M. Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne. JAMA Dermatol. 2015;151(9):941–4. https://doi.org/10.1001/jamadermatol.2015.34. 7. Quinn M.  Prevalence of androgenic alopecia in patients with polycystic ovary syndrome and characterization of associated clinical and biochemical features. Fertil Steril. 2014;101(4):1129–34. https://doi. org/10.1016/j.fertnstert.2014.01.003. 8. Roos N, Kieler H, Sahlin L, et  al. Risk of adverse pregnancy outcomes in women with polycystic ovary syndrome: population based cohort study. BMJ. 2011;343:d6309.

10

Rosacea David Buckley

Key Points

10.1 Introduction

• Rosacea is an inflammatory disease most commonly found in fair (type 1 and 2) skin. • Most patients have papules, pustules and telangectasia (broken veins) but no comedones. • All patients with rosacea should protect their face from ultra violet light. • Topical steroids aggravate rosacea.

Rosacea is also known as “the curse of the Celts”. It is most commonly seen in type 1 and type 2 skins and affects up to 13.9% of the Irish population. There is a positive family history in 30% of patients. It is 2–3 times more common in females. It is sometimes referred to as “acne rosacea” although it is a different disease to acne.

What to Tell the Patient

10.2 Clinical Features and Diagnosis

• There are safe, effective treatments for rosacea. • Rosacea often goes through phases of relapse and recurrence. • It is vital to protect the facial skin from natural and artificial ultraviolet light by the careful use for a SPF 30 or greater and a broad rimmed hat when outdoors. • Mild cases will respond to topical treatments. • More troublesome cases may need topical and tablet treatments. • It usually takes 6–12 weeks to get a good response from rosacea treatments. • If you are left with a lot of redness after a course of rosacea treatment, you may benefit from laser treatment for your broken veins.

It usually presents with multiple small papules and pustules (pimples) on the face with a red background due to telangiectasia (Figs. 10.1 and 10.2). The rash, which is confined to the face, is usually symmetrical affecting the convex areas of the centre of the face (cheeks, nose, forehead or chin). Some cases can be unilateral. Eye involvement (usually blepharitis) can occur in more that 50% of patients and can be the presenting feature in up to 20% of patients with rosacea (Fig. 10.3a, b). Rosacea is diagnosed clinically as there is not definitive biochemical or histological diagnostic features (Tables 10.1 and 10.2).

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland e-mail: [email protected] © Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_10

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a

Fig. 10.1  Typical rosacea

b

Fig. 10.3 (a) Rosacea of the nose and eyes. (b) Blepharitis associated with rosacea

10.3 Differential Diagnosis Rosacea can be confused with other papular- pustular rashes on the face (acne, peri oral dermatitis, folliculitis, drug eruptions) or conditions that cause a red face such as sebrrhoeic dermatitis, psoriasis, telangectasia, keratosis pilaris, lupus, Fig. 10.2  Severe rosacea

10 Rosacea

67

cellulitis, steroid damage, photosensitivity, or dermatomyositis (see Chap. 17 on the red face).

10.4 Pathophysiology The hair follicle mite (demodex folliculorum), which is a normal inhabitant on the facial skin, is often found in excessive amounts in the skin in patients with rosacea but their role in the pathophysiology of rosacea is unclear. Treatments that reduce the amount of mites on the skin (e.g. ivermectin or metronidazol) seem to help with rosacea. Rosacea is an inflammatory process [1]. If there is redness (telangiectasia) but no papules or pustules then it may not be rosacea, just simply broken veins (Heliodermatitis). Rosacea can be distinguished from acne by the redness of the skin and Table 10.1  Guidelines for the diagnosis of rosacea Presence of one or more of the following primary features:  Flushing (transient erythema)  Permanent erythema  Papules and pustules  Telangiectasia May include one or more of the following secondary features:  Burning or stinging  Plaques  Dry appearance  Oedema  Ocular manifestations: (Blepheritis, styes, chalazia, and corneal damage)  Phymatous changes

the absence of comedones (blackheads and whiteheads) (Fig. 10.4). Rosacea usually occurs in an older age group than those with acne (over 30 years old) but some unfortunate individuals can grow out of acne and into rosacea. At a certain stage some of these patients might have features of both conditions (“red acne”). Fortunately, many of the treatments for acne can also help rosacea (azelaic acid gel or oral tertalyclines). Rosacea can occasionally be seen in teenagers. Unlike acne, rosacea is usually made worse by ultraviolet light, so strict sun avoidance is important. Patients with rosacea may also flush or blush easily and should avoid anything that causes blushing (e.g. stress, excess heat, strenuous ­exercise). Topical steroids (TS) (even weak ones) should be strictly avoided in rosacea. While they may give a temporary improvement at the beginning of treatment, the condition worsens if TS are continued long term. Rosacea can flare up badly if the TS is stopped suddenly without topical or oral treatments as outlined below. There is not good evidence to implicate food as a cause or aggravating factor in rosacea. However, it may help if patients avoid foods or drinks that make them flush or blush (e.g. spicy foods, caffeine, alcohol). They should also avoid excessive heat such as saunas or sitting close to a hot fire. Smoking and alcohol consumption make rosacea more severe. Green based cosmetic camouflage may help hide the redness. The Red Cross and the UK based charity, Changing Faces, can help with cosmetic camouflage.(www.changingfaces.org.uk).

Table 10.2  Subtypes of rosacea Erythematotelangiectatic Papulopustular Phymatous Ocular

Steroid rosacea

Flushing and persistent central facial erythema with or without telangiectasia. Persistent central facial erythema with transient, central facial papules or pustules or both. Thickening skin, irregular surface nodularities and enlargement. May occur on the nose, chin, forehead, cheeks, or ears. Foreign body sensation in the eye, burning or stinging, dryness, itching, ocular photosensitivity, blurred vision, telangiectasia of the sclera or other parts of the eye, or periorbital edema. Severe papules, pustules and telangiectasia which are aggravated by sudden withdrawal of the topical steroid

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Fig. 10.4  Rosacea with no comedomes

10.5 Topical Treatments Rosacea is a chronic disease with periods of relapses and remissions which can continue for many years. It is usually worse in pregnancy. Treatment of rosacea is usually either with topical or oral medication or both. Most mild cases will respond to topical metronidazole or azelaic acid 15% gel for 6–12  weeks. Topical ivermectin 1% cream (“Soolantra®”, an antiparasitic agent) is considered more effective than metronidazole and only has to be applied once a day for 6–12  weeks. With topical ivermectin there are no concerns about antibiotic resistance. It should be applied all over the face and not just on the red areas. If facial flushing is a problem, “Mervaso Gel®” (brimonidine tartrate) may help but rebound flushing can occur in up to 20%.

10.6 Systemic Treatments More severe cases may need the addition of an oral antibiotic which has a strong anti-­ inflammatory action such as a lymecycline or doxycycline. Lymecycline is normally prescribed in the same dose as acne for 1–3  months (300  mg daily). Doxycycline 100 mg daily can cause photosensitivity so all patients should be warned about this unusual side effect. Low dose doxycycline (40 mg

D. Buckley

daily) in a modified slow release capsule (“Efracea®”) can be effective and safe in milder forms of rosacea and does not promote bacterial resistance. Oral minocyclin (100 mg OD), oral metronidazole or oral ivermectin may help in more severe cases. Oral erythromycin 500 mg BD may be helpful in severe flare-ups in pregnancy. Severe, resistant cases of rosacea might require low dose isotretinoin (0.3 mg/ kg/day) or laser treatment. Sometimes 10 or 20 mg of oral isotretinoin three times per week might be sufficient to control rosacea. Topical and oral medications mentioned above for rosacea will help primarily with the inflammatory features of rosacea (papules and pustules). However some patients may be left with persistent redness and telangiectases after clearing their papules and pustules. The redness may respond to cooling creams kept in the fridge, brimonidine gel (“Mirvaso®”), cosmetic camouflage or laser treatment. Some cases of flushing may respond to beta blockers such as propranolol or carvedilol. Eye symptoms such as blepharitis conjunctivitis, and irregularity of the eyelid margins may respond to eye lubricants or metronidazole gel applied to the eyelids. Meibomian gland dysfunction causing chalazion or chronic staphylococcal infection that can cause hordeolum (stye) may also occur with ocular rosacea. Some patients may have decreased visual acuity caused by corneal complications (punctate keratitis, corneal infiltrates/ulcers, or marginal keratitis). These more serious eye problems may need the assessment of an ophthalmologist and treatment with cyclosporine eye drops, oral antibiotics as mentioned above or low dose isotretinoin. Washing the eyelids with diluted Tea Tree oil and applying topical metronidazole or ivermenctin carefully to the eyelids may also help. Topical steroid eye ointments or drops should be avoided. Some patients with rosacea may develop rhinophyma which causes thickening of the skin on the nose with enlargement of the sebaceous glands (Fig. 10.5). This can lead to a red bulbous

10 Rosacea

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nose which can be unsightly and the patient may be mistakenly accused of being a heavy drinker. Thickening of the skin can also rarely affect the chin (gnathophyma), the ear (otophyma) or the forehead (metophyma). It is much more common in males and in some cases may need surgical treatment to correct the deformity.

10.7 Conclusion With careful treatment using topical rosacea agents and/or systemic agents, most flare ups of rosacea can be settled within 6–12  weeks. Photo protection with a factor 30 SFP or greater and a broad brimmed hat should help prevent relapses.

Reference Fig. 10.5  Rhynophyma and rosacea

1. Del Rosso JQ, Gallo RL, Kircik L, et al. Why is rosacea considered to be an inflammatory disorder? The primary role. J Drugs Dermatol. 2012;11(6):694–700.

Hidradenitis Suppurativa

11

David Buckley

Key Points • Hidradenitis Suppurativa (HS) is a chronic inflammatory disease resulting in papules, pustules and sometimes cysts and abscesses most commonly found in the axillae, groin, perianal and under the breasts in young adults. • It is three times more common in females. • There are many possible causes including genetic, hormonal, autoimmune, infective and inflammatory factors. • Almost all cases of HS, regardless of the severity, can now be treated with appropriate topical, systemic and/or surgical treatments.

What to Tell the Patient • HS can lead to embarrassment, anxiety and even depressions especially in severe cases. • HS can be painful and can affect your quality of life causing difficulty with work, sports, sex and leisure activities. • Fortunately HS is a treatable condition. • Treatments can be slow and it can take 3–6 months to see a significant improvement. • Most patients will require a combination of topical and tablet treatments for at least 6 months. D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland

• Severe cases may require injection treatments with the newer biological agents and perhaps surgical treatments.

11.1 Introduction Hidradenitis Suppurativa (HS) is a chronic inflammatory disease affecting the apocrine gland-bearing skin. It usually presents with recurrent nodules and abscesses (“boils”) which result in sinus tract formation and scarring. Papules and pustules can occur. It typically affects the axillae, the groin, the perianal area or under the breasts in young adults. As it can resemble acne (although not in a classical acne distribution), it is sometimes referred to as “acne inversa”. However, unlike acne, HS can be a much more deep-seated chronic, inflammatory condition that progresses onto nodules and cysts with recurrent abscesses, sinuses and hypertrophic or atrophic scars (Figs. 11.1 and 11.2).

11.2 Clinical Features and Diagnosis The diagnosis of hidradenitis suppurative is clinical (Table 11.1). Most patients present with bilateral, recurrent painful papules, pustules, nodules, cysts, sinuses or scars in the axillae, groin and sometimes under the breasts and perianal area.

© Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_11

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with pain and smelly discharge. Secondary infection can occur. HS severity can be classified as in the Hurley stages (see Table 11.2). HS, especially stage 2 and 3, can have considerable effects on the patient’s quality of life because of chronic pain and smelly discharge which can lead to social isolation, low self-esteem, depression and even suicide [1].

11.3 Differential Diagnosis Fig. 11.1  Severe hidradenitis suppurativa in the axilla. Credit: Myriam Raquel González Oviedo

Milder forms of HA may be confused with acne or boils. More severe cases can be confused with deep seated infections, tumours or cutaneous manifestations of inflammatory bowel diseases (Crohn’s). (see Table  11.3). Underlying factors such as diabetes or anaemia which can aggravate HS should be sought (Table 11.4) [2].

11.4 Pathophysiology

Fig. 11.2  Severe hidradenitis suppurativa in the groin. Credit: Myriam Raquel González Oviedo

The etiology of HS is unclear. There can be genetic, hormonal, autoimmune, infective and inflammatory factors [3]. HS is three times more Table 11.2  Hurley stages for hidradenitis suppurativa

Table 11.1  Diagnostic criteria of hidradenitis suppurativa (adopted by the Second International Conference on Hidradenitis suppurativa, March 5, 2009, San Francisco, CA US) 1. Typical lesions, i.e., deep-seated painful nodules: ‘blind boils’ in early lesions; abscesses, draining sinuses, bridged scars and ‘tombstone’ doubleended pseudo-comedones in secondary lesions 2. Typical topography, i.e., axillae, groins, perineal and perianal region, buttocks, infra and inter mammary folds 3. Chronicity and recurrences All three criteria must be met for establishing the diagnosis

Milder cases may be diagnosed as simple boils but the recurrent nature and distribution of the sores should help make the diagnosis. Severe cases are more obvious with recurrent abscesses, sinuses and scars. Lesions persist for months

• Stage 1—solitary or multiple isolated abscesses without scarring or sinus tracks • Stage 2—recurrent abscesses, single or multiple widely separated lesions with sinus track formation • Stage 3—diffuse or broad involvement with multiple interconnecting sinus tracks and abscesses Table 11.3 Differential suppurativa

diagnosis

of

hidradenitis

Infections:  Bacterial—Carbuncles, furuncles, abscesses, ischiorectal/perirectal abscesses, Bartholin’s duct abscess  Mycobacteria—TB  STI—Granuloma inguinale, lymphogranuloma venereum, syphilis  Deep fungi—Blastomyces Tumors or cysts:  Epidermoid cysts, Bartholin’s cysts, pilonidal sinus Miscellaneous:   Crohn’s disease, anal or vulvovaginal fistulae

11  Hidradenitis Suppurativa Table 11.4  Investigation for patients with hidradenitis suppurativa • Full blood count • Urea and electrolytes, liver function test • Random blood glucose and HbA1c • B12, folate, ferritin • Thyroid function test • ESR and C-reactive protein (CRP) • Coeliac antibody test • Test for polycystic ovarian syndrome in females, especially if they show other features of PCOS such as acne, hirsutism, amenorrhoea or cysts in their ovaries

common in females and usually starts in the late teens or early twenties. More severe cases however are more common in men. Family history is positive in one-third of patients with hidradenitis suppurativa [4]. Although hidradenititis suppurativa appears to be a follicular disorder in the apocrine gland bearing skin the exact aetiology of HS are not fully known. The initial event appears to be occlusion of the hair follicle [5]. HS can persist for many years but is unusual after the menopause. It is more common in smokers and those who are overweight [5]. It can be associated with other dermatological conditions such as acne, psoriasis, polycystic ovarian syndrome and pyoderma gangrenosum [5]. It is more common in people with diabetes, inflammatory bowel disease (Crohns) and metabolic syndrome [4]. Complications of hidradenitis suppurativa include lymphoedema, fistula formation (into urethra, bladder, or rectum), anaemia, arthritis and rarely secondary amyloidosis. Squamous cell carcinoma can arise in long standing lesions particularly in the buttock area, and in male patients [5].

11.5 Treatment All stages of HS may be helped by general lifestyle modification by such as losing weight and smoking cessation. Reducing friction and moisture in affected areas by wearing loose clothing and fragrance-free antiperspirants may help. Washing with an antiseptic such as chlorhexidine

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(“Hibiscrub®”) or taking “Milton baths®”, twice a week, can help prevent recurrent infections (see Chap. 66). Stage 1 disease may respond to various topical antibacterial therapies such as topical clindamycin lotion 1% for a maximum of 12 weeks [5]. Acutely infected cysts, nodules or sinuses may respond to a short course of an oral antibiotic such as flucloxacillin 500 mg four times a day for 7–14 days. Abscesses may need to be surgically drained under local anaesthetic or general anaesthetic. Stage 1 and 2 disease may require oral anti-­ inflammatory treatment with long courses of systemic anti-acne type antibiotics such as lymecycline, 300  mg daily or doxycycline, 100 mg daily for at least 4 months. As in acne, more severe disease may benefit from higher doses of these drugs such as lymecycline 300 mg twice a day or doxycycline, 100 mg twice a day for at least 3–6 months [6]. Females may respond to long courses of combined oral contraceptive with an anti-androgenic progesterone such as drospirenone (e.g. ‘‘Yasmin®”) or cyproterone acetate (‘‘Dianette®”). These combined oral contraceptive pills have a slightly higher incidence of thromboembolic events compared to the older second generation or the newer fourth generation pills. They should not be used long-term in smokers, patients who are grossly obese, patients with hypertension or a history of thromboembolic disease. Spironolactone may be a safer option in these high risk groups. Acute flare-ups of nodules or cysts may respond to intralesional steroids. Short courses of systemic steroids (0.5–0.7 mg/kg/day) may help acute flare-ups in some patients with HS [5]. Chronic stage 2 and 3 disease may require a 12 week course of clindamycin, 300  mg BD combined with rifampicin, 300  mg BD [7]. Patients should be warned that rifampicin can discolour urine and tears to red. Rifampicin is a potent inducer of some of the cytochrome P450 enzymes and therefore can also influence the metabolism of other drugs such as anticonvulsants or the oral contraceptive pill [8]. The combination of clindamycin and rifampicin may cause pseudo-membranous colitis so a patient

D. Buckley

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should be warned to report to the doctor if they develop persistent diarrhoea on this treatment. Dapsone, oral retinoids such as acitretin or oral ciclosporin may be necessary in more persistent cases [5]. Severe stage 3 disease may require high dose TNF alpha inhibitors such as adalimumab (‘‘Humira®”) given by weekly subcutaneous injections or infliximab (“Remicade®”) given by IV infusion every 2–6  weeks [5]. Ironically, these TNF alpha inhibitors can paradoxically induce new onset HS when used for conditions such as arthritis, psoriasis or inflammatory bowel disease [9]. Stage 2 and 3 disease may require surgical treatment such as incision and drainage, deroofing of nodules, abscesses or sinuses or radical excision of the entire affected area with skin grafting [10, 11].

11.6 Conclusion Hidradenitis suppurativa is a disorder of the terminal follicular epithelium in the apocrine gland– bearing skin. This condition is a chronic disabling disorder mainly in young adults that frequently cause painful, smelly nodules, cysts and abscesses leading to sinus tracts and scarring. This can result in keloids, contractures, and immobility. Even mild disease can have a profound effect on the patient’s quality of life. Milder cases respond to oral treatments similar to those used for acne. More severe cases may require surgery, long term oral antibiotic combinations or some of the newer biological therapies such as the TNF alpha inhibitors.

11.7 Useful Information for Patients Is Available from the Following Sites irishskinfoundation.ie patient.co.uk

Hidradenitis Suppurativa Foundation (UK): http://www.hs-foundation.org/ The Hidradenitis Suppurativa Trust (USA): www.hstrust.org

References 1. Delany E, et  al. A cross-sectional epidemiological study of hidradenitis suppurativa in an Irish population (SHIP). J Eur Acad Dermatol Venereol. 2018 Mar;32(3):467–73. https://doi.org/10.1111/ jdv.14686. 2. Bui TL, et  al. Hidradenitis suppurativa and diabetes mellitus: a systematic review and meta-analysis. J Am Acad Dermatol. 2018 Feb;78(2):395–402. https://doi. org/10.1016/j.jaad.2017.08.042. 3. Slade DEM, Powell BW, Mortimer PS. Hidradenitis suppurativa: pathogenesis and management. Br Assoc Plast Surg. 2003;56:451–61. 4. Schrader AM, Deckers IE, van der Zee HH, Boer J, Prens EP.  Hidradenitis suppurativa: a retrospective study of 846 Dutch patients to identify factors associated with disease severity. J Am Acad Dermatol. 2014 Sep;71(3):460–7. 5. Zouboulis CC, et  al. European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa. J Eur Acad Dermatol Venereol. 2015 Apr;29(4):619– 44. https://doi.org/10.1111/jdv.12966. 6. Tan J, et  al. A treatment for severe nodular acne: a randomized investigator-blinded, controlled, noninferiority trial comparing fixed-dose adapalene/benzoyl peroxide plus doxycycline vs. oral isotretinoin. Br J Dermatol. 2014 Dec;171(6):1508–16. https://doi. org/10.1111/bjd.13191. 7. van der Zee HH, Boer J, Prens EP, Jemec GB.  The effect of combined treatment with oral clindamycin and oral rifampicin in patients with hidradenitis suppurativa. Dermatology. 2009;219(2):143–7. 8. SmPC Rifadin® (rifampicin). www.medicines.ie. Accessed 02 Mar 2018. 9. Faivre C, Villani AP, Aubin F, et  al. French society of dermatology and club rheumatisms and inflammation. Hidradenitis suppurativa (HS): an unrecognized paradoxical effect of biologic agents (BA) used in chronic inflammatory diseases. J Am Acad Dermatol. 2016 Mar 7:S0190-9622(16)00066-9. https://doi. org/10.1016/j.jaad.2016.01.018. 10. Kohorst JJ, et al. Surgical management of Hidradenitis Suppurativa: outcomes of 590 consecutive patients. Dermatol Surg. 2016 Jun 21;42(9):1030–40. 11. Buimer MG, Wobbes T, Klinkenbijl THG. Hidradenitis suppurativa. Br J Surg. 2009;96:350–60.

Hyperhidrosis (Excessive Sweating)

12

David Buckley

Key Points • Excessive sweating can be localized (e.g. hands or feet) or generalized, primary or secondary. Generalised hyperhidrosis is more likely as a result of an underlying condition. • If the generalized sweating is of recent onset and/or associated with other symptoms such as fever, weight loss, fatigue or swollen glands, then a thorough search for an underlying cause should be made. • Treatment of generalised hyperhidrosis is usually by dealing with the underlying cause and perhaps with systemic medicines. • Localised hyperhidroses is often idiopathic (of no known cause) and may be hereditary. • Primary idiopathic focal hyperhidrosis usually stops during sleep. • Focal hyperhydrosis often responds to local measures such as powerful antiperspirants, iontophoresis or botulinum toxin (Botox©).

away from the body and an ultra-thin, extremely breathable, sweat-repellent exterior to block sweat stains from showing. Open sandals or leather soled shoes can also help. • Self help groups such as www.sweathelp.org or www.hyperhidrosisuk.org are great resources for patients.

12.1 Introduction

Hyperhidrosis is a disease characterised by sweating (perspiration) in excess of the normal physiologic amount necessary to maintain body temperature. Primary or idiopathic hyperhidrosis and secondary hyperhidrosis are the two main categories. Patients can have excessive sweating either in a localized area (focal) or over the entire body (generalised). Primary disease is usually localized, affecting the soles, palms, and axillae in various combinations and with varying degrees of severity (Fig. 12.1). Secondary hyperhidrosis can be generalised or focal. In secondary hyperWhat to Tell the Patient hidrosis the symptoms are due to one of a large number of medical conditions, including endo• Wearing appropriate clothing and pads may crine disorders, neurological problems, use of help. Staying calm and cool is also important. certain drugs, cancer, chronic infections, derma• Special garments are available with a sweat-­ tologic syndromes, and conditions associated absorbent wicking interior that pulls sweat with excess catecholamine discharge (Table 12.1). D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland © Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_12

75

76

Fig. 12.1  Hyperhidrosis of the feet

Table 12.1  Causes of generalized sweating Infections: Acute viral or bacterial infections; chronic infections, e.g.: TB, malaria, brucellosis. Drugs: Alcohol, cocaine, heroin, ciprofloxacin, acyclovir, esomeprazole, antidepressents, propranolol, etc. Endocrine: Diabetes, hyperthyroidism, menopause, pregnancy, carcinoid syndrome, hyperpituitarism, pheochromocytoma, acromegaly. Neurological: Stroke, spinal cord injury, gustatory after parotidectony or primary gustatory, Parkinson’s disease. Others: Lymphoma and other myeloproliferative disorders, congestive cardiac failure, anxiety, obesity, rheumatoid arthritis.

12.2 Clinical Features and Diagnosis Some patients can be very embarrassed with their excessive sweating which can ruin clothes, make writing or shaking hands difficult and can interfere with certain occupations or sports

D. Buckley

(e.g.: golf, tennis, rock climbing). Bromohydrosis (smelly sweating) can often make the problem even more troublesome for the patient. Many are reluctant to seek medical help in the mistaken belief that nothing can be done. Idiopathic focal hyperhidrosis usually starts in childhood although many patients delay seeking medical help until they reach adult life. Between a third and half of the patients have a positive family history. Interestingly, idiopathic focal hyperhidrosis does not cause excessive sweating during sleep. Hyperhidrosis is usually diagnosed clinically. If the presentation is characteristic of primary focal hyperhidrosis and there is no evidence of an underlying cause, no laboratory tests are required. If there is a suspicion of secondary hyperhydrosis due to some medical condition special tests and investigations may be required (Table 12.2). There are various methods to quantify the amount of sweat being produced on the palms or axilla such as gravimetric measurement. This test is often utilized in clinical trials and is not part of routine clinical practice. After drying the surface, a pre-weighed filter paper is applied to the palm or axilla for a period of time measured by stopwatch. The paper is then weighed and the rate of sweat production is calculated in mg/min. >20 mg/min in men and >10 mg/min in women in the axilla is considered excessive.

Table 12.2  Investigations for hyperhidrosis if an underlying medical cause is suspected • Full blood count • Blood film for malarial parasites if overseas travel • ESR and/or CRP • Renal function tests and electrolytes • Liver function tests • Fasting blood glucose or HBA1C • Thyroid function tests • Chest x-ray (may be useful to identify an intrathoracic neoplasm) • HIV testing • Urinalysis • Hormonal studies in women in the perimenopausal age group (LH, FSH + oestrogen)

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12.3 Differential Diagnosis Excessive sweating may be focal or generalised, primary or secondary. Most cases of generalised sweating are due to an underlying cause (see Tables 12.1 and 12.3). If the generalised sweating is of recent onset and/or associated with other symptoms such as fever, weight loss, fatigue or swollen glands, then a thorough search for an underlying cause should be made (Table 12.2). Focal hyperhidrosis is far more common and can affect up to 1% of the population (Table 12.4). It usually affects the hands, feet, axilla, face or scalp. Treatment depends on the location, the severity and the ability of the patient to cope.

12.4 Pathophysiology Although the exact pathophysiology of primary hyperhidrosis is yet to be determined, there is much evidence for abnormalities in autonomic nervous system function. Since hyperhidrosis often begins in childhood and can be familial, the

physiologic basis for this disorder may be genetically determined [1]. Sweat glands in patients with hyperhidrosis are not histopathologically different from those in normal patients, nor is there an increase in the number or size of glands. The condition is caused by hyper function of the sweat glands rather than hypertrophy [2]. Patients with primary hyperhidrosis have a higher-than-normal basal level of sweat production as well as an increased response to normal stimuli such as emotional or physical stress.

12.5 Treatment Simple measures include frequent showers, loose clothing, wearing black or white shirts, antiperspirants and deodorants may help. Special garments are available with a sweat-absorbent wicking interior that pulls sweat away from the body and an ultra-thin, extremely breathable, sweat-repellent exterior to block sweat stains from showing. Patients should avoid triggers such as excessively hot rooms or spicy foods. Leather soled shoes or open sandals may help with sweaty

Table 12.3  Hyperhidrosis assessment: Hyperhidrosis

Generalised

Focal

Primary idiopathic focal hyperhidrosis

-Mostly hand, feet and/or axilla, -Bilateral and relatively symmetrical, -Impairs daily activity, -At least one episode a week, -Age of onset usually less than 15 years, -Positive family history in most cases, -Cessation of sweating during sleep, -no drug causes, -otherwise healthy.

Secondary focal hyperhidrosis

-Spinal cord injury, -Raynaud’s phenomenon, -AV fistula, -Reflex sympathetic dystrophy, -Erythromelalgia.

Infections

Acute viral or bacterial infections; Chronic infections, e.g.: TB, Malaria, Brucellosis.

Drugs

Alcohol, Cocaine, Heroin, Ciprofloxacin, Acyclovir, Esomeprazole, Antidepressants, Propranolol, etc.

Endocrine

Neurological

Diabetes, Hyperthyroidism, Menopause, Pregnancy, Carcinoid syndrome, Hyperpituitarism, Pheochromocytoma, Acromegaly.

Stroke, Spinal cord injury, Gustatory after parotidectomy or primary gustatory, Parkinson’s disease.

Others

Anxiety, Lymphoma and other myeloproliferative disorders, Congestive cardiac failure, Obesity, Rheumatoid arthritis.

78 Table 12.4 Criteria for diagnosing ideopathic focal hyperhidrosis Focal, visible, excessive sweating for at least 6 months duration without any apparent cause and with at least 2 of the following • Bilateral and relatively symmetrical • Impairs daily activity • At least one episode a week • Age of onset less than 15 years • Positive family history • Cessation of sweating during sleep

feet. Adsorbent insoles and disposable axillary pads can also be extremely helpful. Self help groups can be very supportive for patients (See Patient information leaflet on Chap. 66). Many patients may have already tried these simple methods. Assuming there is no underlying cause, the next step is to try a more potent antiperspirant such as 20% aluminium chloride (“Driclor®”, “Anhydrol Forte®” or “Sweat Stop®”). These usually come as a role-on or spray and can be used on the axilla, hands or feet. Aluminium chloride is a metal salt that physically blocks the ducts that drain the sweat glands. They come in various strengths. A 20% solution is the standard strength but lower concentrations may be necessary for the face and axilla and higher concentrations may be required for the hand and feet. Aluminium chloride can be quite irritating initially and should be applied overnight and washed off in the morning every second day for the first week or two. If there is a lot of irritation at the start of treatment a potent topical steroid may help if applied in the morning for the first week or two. It may take up to 2 weeks to see results with aluminium chloride. An ordinary antiperspirant/deodorant can be used in the morning during treatment. If topical agents do not help, the next treatment to consider is iontophoresis. This is applied using shallow trays filled with water and a small electrical current from a battery is passed through the water. The exact mechanism of action is unclear but this method can significantly reduce focal sweating in 85% of patients. The hands and/

D. Buckley

or feet can be placed in the trays for 20–30 min alternate nights initially but the frequency can be reduced after 2–3 weeks to twice a week if there is a response. “Idrostar®” has a direct pulsed current which is more suitable for children and those with sensitive skin and it also comes with axillary pads (www.iontophoresis.info). 0.05% glycopyrrolate solution can be added to water to enhance the response. Most patients buy their own unit for home use. For axilliary hyperhidrosis small arm pads soaked in water and attached to the machine may help but the best results are obtained when iontophoresis is used for the hands and feet. It should not be used in patients with pacemakers, metal implants or in pregnancy. For severe resistant cases of hyperhidrosis, botulinum toxin (e.g. “Botox®”) can be very effective. It is given intradermally and blocks acetylcholine release and neurotransmission. It is most suitable for axillary hyperhidrosis and can cause 75–100% reduction in sweating for up to 6–9 months. It is less effective and more painful to use on the hands. Generalised hyperhidrosis is best managed by dealing with the underlying cause (see Table 12.1). Oral anticholinergics, which are normally licensed for urinary frequency, can be very helpful in patients with generalised hyperhidrosis or patients with severe resistant forms of focal hyperhidrosis. They are contraindicated in patients with myasthenia gravis, pyloric stenosis, and ileus and they need to be used with caution in patients with narrowing angle glaucoma, gastro-­ oesophageal reflux, bladder outlet obstruction and heart failure. Probanteline bromide 15–30 mg three times a day, later increasing to 50 mg three times a day as required, may help. Oxybutyline 2.5 mg daily, gradually increasing to 2.5 or 5 mg twice a day is also useful. “Lyrinel XL®” 5  mg once daily is a new long acting oxybutynin anticholinergics which has a convenient once a day dose. Some patients may need to gradually increase the dose up to 30 mg daily. Dry mouth is a problem with all anticholinergics, especially at high doses [3].

12  Hyperhidrosis (Excessive Sweating)

Other drugs worth considering are beta blockers (e.g. propranolol 40 mg tid) or calcium channel blockers (e.g. diltiazem 60  mg tid). These may take 2 weeks before patients will see results. Peri-menopausal sweating is best dealt with by hormone replacement therapy (HRT). For women who cannot or will not take HRT, clonidine, methyldopa or SSRI anti-depressants may help [4, 5]. Endoscopic thoracic sympathectomy was used in the past but it can cause compensatory hyperhidrosis in other areas of the body in up to 60% of cases and there have been some fatalities with this procedure which has now fallen out of favour. Laser sweat gland ablation for axilliary hyperhidrosis is coming on stream but its effectiveness is yet to be established. Facial hyperhidrosis can be difficult to manage. Topical 0.5% glycopyrronium bromide cream (100 g) is expensive but may help. Weaker forms of aluminium chloride combined with Aloe Vera are available in a spray formulation which can be used on the face (“Sweat Stop®”). Oral anticholinergics can be used in severe cases of facial hyperhydrosis. Some patients with foot hyperhidrosis may develop pitted keratolysis. This causes multiple small white smelly pits on the sole of the feet usually sparing the arch of the foot. It is usually caused by several bacterial species including kytococcus and corynebacteria species. Treatment is with a topical antibiotic such as fusidic acid (“Fucidin®”) twice a day for 7–14  days. More severe cases may respond to oral antibiotics such as erythromycin for 7 days followed by measures outlined above to reduce sweating.

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12.6 Conclusion Excessive sweating is a common and embarrassing condition. A careful history, a thorough physical clinical examination and investigations may be necessary to distinguish between primary idiopathic hyperhidrosis and hyperhidrosis secondary to an underlying medical condition. Fortunately most cases of primary idiopathic hyperhidrosis can be managed with topical therapies, oral medications, botulinum toxin or special techniques such as iontophoresis. Useful Website http://www.sweathelp.org/ (USA site) www.hyperhidrosisuk.org (UK site)

References 1. Ro KM, Cantor RM, Lange KL, Ahn SS.  Palmar hyperhidrosis: evidence of genetic transmission. J Vasc Surg. 2002;35:382–6. 2. Heckmann M. Hyperhidrosis of the axilla. Curr Probl Dermatol. 2002;30:149–55. 3. Benson RA, Palin R, Holt PJ, Loftus IM. Diagnosis and management of hyperhidrosis. BMJ. 2013 Nov 25;347:f6800. 4. Haimov-Kochman R, et  al. Hot flashes revisited: pharmacological and herbal options for host flashes management. What does the evidence tell us? Acta Obstet Gynecol Scand. 2005;84:972–9. 5. Deirdre DR, Jason JM, Loprinzi CL. Management of menopause-associated vasomotor symptoms: current treatment options, challenges and future directions. Int J Women's Health. 2010;2:123–35.

Part III Papulosquamous and Eczematous Dermatoses

Atopic Eczema in Children

13

David Buckley

Key Points • Atopic eczema (AE) is an extremely itchy condition. If there is little or no itch, reconsider the diagnosis. • AE is a chronic disease that can often last years and may go through flare ups and remissions. • AE is often associated with other atopic diseases in the patient or other first degree relatives (asthma, allergic rhinitis, allergic conjunctivitis). • AE is a genetic condition which causes dry skin and a defective skin barrier which makes the patient prone to infections, irritants and allergens. • The cornerstone of treatments is emollients which will restore the skin barrier, reverse the dryness of the skin and ease itch. • Topical steroids are safe and effective once used within the guidelines and under careful medical supervision.

• Children with AE have very sensitive skin and should avoid soaps, detergents, perfumes and wool next to their skin • Dry, sensitive skin is the basic underlying problem and liberal, frequent applications of a safe greasy moisturisers is the key to success • Liberal applications of an emulsion-type moisturiser applied daily during the first 32 weeks of a baby’s life may help prevent the development of atopic eczema in those children at risk because of their family history • Most children with mild to moderate eczema do not require allergy testing or restrictive diets • Topical steroids are safe when used under careful medical supervision • Feeding children peanuts (in pureed form) early in childhood may prevent the onset of peanut allergy later in childhood

13.1 Introduction What to Tell the Patient • Atopic eczema is very common affecting approximately one in five children • Most children with mild to moderate eczema will outgrow their skin condition in time D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland

Atopic eczema (AE) is a common chronic, itchy inflammatory skin disorder that usually lasts months or years. It can affect up to 20–30% of children and 10% of adults and the incident of atopic eczema is still increasing [1]. Like all chronic diseases, (e.g. asthma, rheumatoid arthritis) it can go thought phases of exacerbations and remissions, although more than 60% of cases of

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childhood eczema will eventually resolve by adulthood. However, most adults who had atopic eczema in childhood will continue to have sensitive skin and may continue to have flare-ups of eczema if exposed to harsh chemicals, (e.g. perfumed soaps, bubble bath) or are in a high risk occupation for contact dermatitis (e.g. nurses, hairdressers, dairy farmers, plasterers etc.). Atopic eczema in childhood can be considered a family disease. AE can severely affect the quality of life not only of the child but also the parents, who are left exhausted and frustrated in trying to manage their child’s chronic itch. There is also a significant financial burden on the family and the state in managing children with atopic eczema.

13.2 Clinical Features and Diagnosis Atopic eczema is a dry, itchy skin condition (see Table  13.1). If there is little or no itch then you should reconsider the diagnosis (see Table 13.2). Most of the clinical features of atopic eczema arise as a consequence of scratching itchy, dry skin. Scratching further compromises the skin barrier function. Therefore, all treatments should be aimed at breaking the itch-scratch cycle. This is primarily achieved by moisturising the skin with the appropiate moisturisers, avoiding soaps and other irritants and targeted therapies with topical calcineurin inhibitors and or topical steroids.

Most children (85%) with AE will develop the itchy rash in the 1st year of life. 95% of patients with AE will develop the rash before the age of 5 years old. There is usually a history of chronic or relapsing disease. In babies, AE can cause a generalised rash (Figs. 13.1 and 13.2); as the child growth, it becomes primarily a flexural rash especially affecting the front of the elbows, the backs of the

Table 13.2  Differential diagnosis for atopic eczema Seborrhoeic dermatitis Psoriasis Scabies Pityriasis Rosea Tinea corporis Numular (discoid) eczema Conact allergic dermatitis Drug rash Ichthyosis Molloscum dermatitis Dermatitis herpetiformis Ichthyosis

Table 13.1  Diagnostic criteria for atopic eczema Must have: An itchy skin condition (or report of scratching or rubbing in a child) Plus three or more of the following: a. History of itchiness in skin creases such as folds of the elbows, behind the knees, fronts of ankles, or around neck (or cheeks in children under 4 years). b. History of asthma or hay fever (or history of atopic disease in a first degree relative in children under 4 years). c. General dry skin in the past year. d. Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children under 4 years). e. Onset in the first 2 years of life (not always diagnostic in children under 4 years).

Fig. 13.1  Atopic eczema (infected on face) in a 5-monthold child

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Fig. 13.3  Atopic eczema in dark skin with post-inflammatory hyperpigmentation in an 11-year-old boy Fig. 13.2  Atopic eczema in a 7-month child which is infected

knees and the neck (Fig. 13.3). The skin is dry with mild erythrema and evidence of scratching (e.g. excoriation, bleeding, scabs or crusts). More severe cases can have generalised dry red itchy skin affection most of the body, face and scalp (Fig. 13.4). Infraorbital folds (Dennie-Morgan folds) are common in patients with AE (25% of patients) and may occur as the eyelids are a site of predilection for AE causing typical extra lines or skin folds under the eyes. Paradoxically, the nappy area in children is often spared. There may be a number of reasons for this. The child may not be able to scratch the area because it is inaccessible. In addition, the occlusive effects of the nappy combined with the natural moisturizing effects of urea may help ease itch and prevent scratching. The most obvious sign of AE in children is the intense scratching which is worse once the child is stripped down to their bare skin. The itch is so severe that distraction rarely stops the scratching.

Fig. 13.4 Atopic eczema in a 4-year-old child not responding to clobetasone butyrate ointment

One can recognize an atopic child by their continuous scratching. Emotional factors can also affect atopic eczema. Children with chronic itch are often tired and irritable as a result of sleep disruption, not

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only for the child but also for the parents. The children may scratch more if they are tired and irritable leading to a vicious cycle of itching and scratching. Older children may scratch their skin in an attempt to manipulate their parents so they can get their own way. Scratching can sometimes become habitual and can be helped by behavioural modification. Like all bad behaviour in childhood, it is best dealt with by praising good behaviour and ignoring bad behaviour as much as possible, especially when children are using their bad behaviour to get their own way. Teaching the child to rub or pinch the itchy skin rather that scratch it may help alleviate itch without damaging the skin.

13.3 Differential Diagnosis (Table 13.2) Other common itchy skin conditions in childhood include scabies but this does not usually have the typical flexural rash. Scabies can mimic many conditions. Seborrhoeic dermatitis and psoriases in children may look similar to AE but these conditions do not usually itch anything as bad as AE. Pityriasis rosea and discoid eczema may itch but their distribution and shape are usually characteristic. Contact irritant and allergic dermatitis are less common in children but there is sometimes an overlap between AE and the other forms of dermatitis (See Table 4 in Chap. 14). As children are on less chronic drugs than adult and the elderly, drug eruptions are less common and usually more obvious in children. Tinea infections can affect the flexures in children and the typical clinical signs may be altered by the inappropriate use of topical steroids (Tinea incognito). This may result in more severe, extensive tinea infections which can be confused with AE. Skin scrapings should be taken if there are any suspicions of a fungal infection. Ichtyosis can cause severe dryness of the skin but it is usually familial and unlike AE, there is normally little or no itch. Children with AE are more prone to infections including Molluscum contagiosum. Molluscum infection can cause an inflammatory reaction resulting in molluscum

dermatitis or a worsening of AE. Dermatitis herpetiformis (DH) can cause a generalised eczematous rash and intense itch. The distribution of DH is usually the opposite of AE (DH usually affects the backs of the elbows, the front of the knees and the scalp). DH may cause tiny vesicles but these are often scratched away before the doctor has time to see them (see Chap. 23).

13.4 Pathophysiology The pathophysiology of atopic eczema remains incompletely understood with a complex interaction between genetic predisposition and environmental triggers. There is often a personal or family history of other IgE related atopic diseases such as asthma, allergic rhinitis or allergic conjunctivitis. Indeed, it has been argued that there is a causal link between eczema and a later onset of allergic rhinitis and asthma (“the atopic march”). About one in every three children with eczema develops asthma or allergic rhinitis during later childhood. Severe eczema, early onset eczema and persistent eczema increase the risks of developing asthma and rhinitis. Recent studies have shown that many children with atopic eczema have a mutation in the gene which encodes filaggrin (FLG) which is a key structural protein in the outermost layer of the epidermis. This can lead to a defect in the skin barrier function making the child more susceptible to irritants (e.g. soaps, bubble baths and shampoos), infections (e.g. staphylococcus aureus, herpes simplex, molluscum contagiosum) and allergens (house dust mite, animal dander, pollen). A useful clinical marker that is found in some children and their families with the FLG mutation is palmar hyperlinearity (i.e. have extra lines on the palmer creases of the hands). In some children with atopic eczema there may also be a defect in the gut barrier function, especially in younger children with more severe atopic eczema, which can lead to allergic reactions to certain foods, such as milk, eggs, nuts, wheat, etc. Children may also be sensitized by the foods entering the system through a defective skin barrier.

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13.5 Treatment The management of AE is multi factorial and will require a combination of non- prescription and prescription items to tackle the various underlying factors including itch, dry sensitive skin, infections and allergies. Because atopic eczema is a chronic disease, the doctor must have strategies for treating acute exacerbations and also for maintenance treatment between exacerbations. Parents need to understand that AE is a chronic condition and they will need to apply treatment depending on the extend of the rash and the severity of the disease at presentation (mild, moderate or severe). The corner stone of treatment is “The 3 E’s” 1. Emollients 2. Education of the child and parents on management of AE 3. Elimination of irritants, allergens and itch. Advice should be given with regards to clothing, feeding, bedroom decor, entertainments like sun bathing and swimming pools. For instance, AD children should avoid sleeping in rooms with many books, rugs or any other dust attracting material (like curtains). Frequent vacuuming is recommended, washing of curtains, leave books out of the room and maintain correct level of humidity. Air allergens may be a trigger for an exacerbation of AD. Avoiding them can be useful for secondary prevention.

Fig. 13.5  Infected atopic eczema

13.6 Skin Infection Regardless of the severity of the presentation, all children with atopic eczema should be assessed for signs of clinical infection. Eczema is a dry, itchy skin condition. If the skin is crusty, weepy or sore then it is most likely infected, usually with Staphylococcus aureus (Figs. 13.5 and 13.6). Staphylococcus aureus is commensal in 10% of children who have no skin problems but is found in up to 90% of children with atopic eczema. If it penetrates intact skin as a result of a defective skin barrier function and or scratching, it can cause clinical infection that can resemble impetigo (impetiginised eczema). Once there is Fig. 13.6  Infected atopic eczema on the face

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clinical infection no treatment will work until the infection is cleared. Keeping eczematous, weepy skin clean is an art: on the one hand, soaps worsen eczema; on the other hand, bacteria need to be removed by washing appropriately. Syndet soaps are great as they tend to protect the skin from further inflammation while eliminating bacteria. Once infected, the child will usually require oral antibiotics such as flucloxacillin or clarithromycin for at least 7 days. Topical antibiotics such as fusidic acid (“Fucidin®” or “Fucidin HC®”) may also be required for a maximum of 7–14 days. Even in the absence of clinical infection, Staphylococcus aureus, which common colonises the skin in children with atopic eczema, can secrete a superantigen, which can lead to release of inflammatory cytokines and worsening of the atopic dermatitis. Strategies to reduce the burden of Staphylococcus aureus in the skin such as with “Milton® (Bleach) baths” twice a week (1 ml/liter of bath water) have been recommended, particularly in children with severe atopic eczema or those with recurrent skin infections although there is not allot of scientific evidence to support the benefits of bleach baths. “Milton Fluid®” is made of an aqueous solution of sodium hypochlorite and 16.5% sodium chloride and it is important to use the correct concentration in the bath. Washing in a bath without soaps, bubble baths and other irritants may be as effective as bleach baths in removing bacteria form the surface of the skin [2]. See patient advice leaflet. (Chap. 66). Children with atopic eczema are also susceptible to viral infections including the herpes simplex virus (HSV). Infections with the HSV can cause eczema herpeticum which is a rare but potentially life threatening infection in children with atopic eczema. It is more common in young children with severe atopic eczema, particularly when it affects the face and neck. It presents as a cluster of vesicles or punched out ulcers which may become secondarily infected with crusting and weeping and may look like impetiginized eczema, which fails to respond to topical and oral antibiotics. Children with eczema herpetiformis usually require hospital admission and systemic treatment with antivirals.

13.7 Moisturisers The ideal moisturiser should be greasy, cheap, available in large quantities and free from irritants such as sodium lauryl sulphate (SLS). Ointments are safer than creams as they contain fewer preservatives. It should be hypoallergenic, perfume and fragrance free. Greasy ointments are messy and sticky. Children sometimes dislike them but parents should persist as they are far more effective than light, creamy, cosmetically more acceptable moisturisers. Parents should be given a choice of a few moisturisers to try out to see which helps their child’s dry skin the best. A greasy moisturiser will remain on the skin much longer and usually only have to be applied twice a day except on the hands, where they should be applied more often as the moisturiser rub off or are washed off more frequently. A greasy moisturise should always be rubbed downwards, especially on hairy parts of the body, as rubbing upwards can irritate the hair and cause folliculitis. Sufficient quantities of moisturisers need to be recommended and as a general rule the parents should be encouraged to use ten times more moisturisers that topical steroids or topical calcineurin inhibitors. A recent Cochrane review showed that moisturisers prolong the time to flare, decrease the number of flares ups and reduce the amounts of topical corticosteroids needed to control eczema. It also showed that topical anti-­ inflammatory treatment in combination with moisturisers yields better results than without moisturisers [3, 4]. Another recent study assessed the benefits of an emulsion-type moisturiser applied daily d­ uring the first 32 weeks of life to 59 of 118 neonates at high risk for AD (based on having a parent or sibling with AD). It showed daily application of moisturiser during the first 32 weeks of life reduces the risk of AD/eczema in infants by 32% [5]. This is a very practical and useful tip for parents of children with atopic eczema to protect their newborn siblings. Emollient therapy in newborns with high risk for AD could be recommended for primary prevention.

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Emollient bath additives have not been proven to help but are far safer than bubble baths and other perfumed bath additives. Moisturisers should be applied immediately after a bath to “seal in” the hydration from the bath water. Adding some powered oat into the bathtub can also help reduce itching. Pat-drying is better than rubbing. Short baths are recommended (less than 5  min). Soap substitures can be used in those areas that requite deeper cleaning such as axila, genitals and feet. (see Chap. 62 on emollients).

13.8 Avoiding Irritants Children with atopic eczema have a defective skin barrier function and are far more susceptible to irritants such as soaps, shampoos, bubble baths, perfumes, fragrances, SLS or preservatives such as paraben. Soaps and shampoos contain

detergents such as SLS, which are designed to break down and remove oil; however, this is a very thing that is in short supply in the skin of children with atopic eczema. Parents should be advised to use suitable soap and shampoo substitutes such as “Elave®” wash, “Elave®” shampoo or “Aveeno®” wash. A cheap, safe alternative is aqueous cream which makes a nice soap substitute. Parents should be warned not to use aqueous cream as a leave-on moisturiser as it contains Sodium Lauryl Sulfate (SLS) which can damage delicate skin if left in contact with the skin for a prolonged period of time.

13.9 S  tepwise Approach to Atopic Eczema (Tables 13.3 and 13.4) All patients with atopic eczema, regardless of the severity, need plenty of moisturising and need to

Table 13.3  Stepwise approach to atopic eczema in children Atopic Eczema in children

If clinical infection give an oral antibiotic and consider Milton baths

At all stages use a greasy moisturiser and avoid soaps and other irritants

Mild Add a week TS to face and body

Worse

worse

Moderate

worse Severe Unresponsive Add a week TS to face Add short course of + moderate TS to body potent TS to bodya better Review the diagnostics. + sedating AH at night better +/-TCI for face and Check compliance. body Check for infectionb. + sedating and Refer to Dermatologist non-sedating AH or Allergist better better + consider allergy testing + consider wet wraps. better

Consider maintenance treatment with twice weekly TS or TCI to “at risk” areas of skin TS Topical steroid, TCI Topical calcineurin inhibiter (e.g. “Protopic”), AH Antihistamine aAvoid using potent TS in children 5 mm), Discrete, Smooth, Dome Shaped, Non-pigmented Nodules If a lesion like this is new and growing, a nodular BCC is as strong possibility. The possibility of a BCC would be further heightened if the lesion were oozing, bleeding, crusting or tender. However, keloids (Fig. 44.14a, b) and sebaceous cysts can also present like this. Keloids usually follow trauma but can arise spontaneously, especially in acne prone skin and in Afro-­Caribbean patients. Sebaceous (epidermoid) cysts normally have a visible punctum, which helps to

b

make the diagnosis. Pilar (trichilemmal) cysts occur in the scalp and have no puntum but contain similar smelly, soft cheesy material as found in a sebaceous cyst. Granuloma annulare can be smooth and dome-shaped but is ­usually made up of a number of nodules in an anular shape.

44.5 Conclusion Any new or changing lesion, regardless of its colour, should be viewed with suspicion and biopsied unless a confident, clinical, named ­diagnosis of a benign lesion can be made on the history, visual inspection and dermoscopy examination if available.

References 1. Martin RC, Scoggins CR, Ross MI, Reintgen DS, Noyes RD, Edwards MJ, et al. Is incisional biopsy of melanoma harmful? Am J Surg. 2005;190(6):913–7. 2. Bong JL, Herd RM, Hunter JA.  Incisional biopsy and melanoma prognosis. J Am Acad Dermatol. 2002;46(5):690–4. 3. Clinical practice guidelines for the management of Melanoma. 2008, p.  35. www.nhmrc.gov.au/_files_ nhmrc/publications/attachments/cp111.pdf

Cancer and Pre-Cancer of the Skin

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Key Points –– The doctor needs skills and knowledge to be able to decide which lesions to ignore, which to treat and how, which to review, which to biopsy and which to refer. –– Any skin lesion where a definitive, named, clinical diagnosis cannot be made should be viewed with suspicion and the lesion should be biopsied or referred to a colleague with more experience in lesion recognition. –– The doctor should always have a high index of suspicion for any new lesion (pigmented or non-pigmented) that is changing in size, shape or colour or looks different from any other lesion on the body and where a confident, named, clinical diagnosis cannot be made. –– Any lesion that is new, firm and growing (NFG) should be viewed with suspicion. –– The incidence of transfer from an actinic keratosis to a squamous cell carcinoma is estimated to be anything from 0.5 to 2% per year but the true figure is unknown. –– Although considered low risk, 5% of Bowen’s disease will progress to SCC so it is important to treat them in the majority of patients. –– Many non-melanoma skin cancers (NMSCs) will be small cancers, and relatively simple to excise. Certain locations (the H area of the face

––

––

–– ––

which includes the nose, ears and lower lip) are prone to metastasise early and others (especially the scalp) may require skin grafting once removed surgically. Unlike squamous cell carcinomas (SCCs), most basal cell carcinomas (BCCs) have little or no potential to spread beyond the skin and are therefore not life threatening. They can be locally destructive and can cause significant morbidity and health expenditure. Diagnosis of BCCs can often be made clinically or with dermoscopy and should be confirmed by biopsy (punch or shave biopsy). Who treats it and how it is treated will depend on the histological subtype, depth of tumour, size in diameter, location, the age and general health of the patient and the skills and experience of the treating doctor. Melanoma may develop from an existing mole but most arise de novo. The prognosis and definitive treatment for melanoma will be dictated by the depth of the tumour (Breslow thickness) and other high risk features such as ulceration, higer Clark levels (4 or 5), high mitotic activity, lymphovascular invasion and whether or not there is local or distant metastasis. Early detection saves lives.

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland © Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_45

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What the Patient Should Know –– A new mole or growth that is changing, different from any other mole or growth on the skin or is sore or tender should be checked by a doctor. (“New Cancers Do Show”). –– Unlike other skin cancers, melanomas can occur at any age but are more common as one gets older. –– A new mole that appears after the age of 40 years old should be viewed as suspicious, and the older the patient, the more suspicious you should be. –– Less than half of all melanomas develop from existing moles. The majority (60–80%) arise from brand new moles.

relying on dermoscopy or a skin biopsy. Taking a punch or shave biopsy is a simple procedure that can be easily carried out in primary care. The skill is deciding which lesions to ignore, which to treat and how to treat, which to review, which to biopsy and which to refer. There are only about ten common benign lesions that occur on the skin (Table  45.1). All doctors should be familiar with these and be able to make a confident, clinical named diagnosis. Any skin lesion where a definitive, named, clinical diagnosis cannot be made should be viewed with suspicion and the lesion should be biopsied, excised or referred to a colleague with more experience in lesion recognition (Fig.  45.2). Table 45.1  Top ten common benign skin lesions

45.1 Introduction There are a number of common invasive skin cancers (BCC, SCC, melanomas) (see Fig. 45.1). While the classical, clinical textbook description may help diagnose a particular type of cancer, often in primary care it may be difficult, if not impossible to tell if a lesion is cancerous and which particular type of skin cancer it is without

Fig. 45.1  All invasive skin cancers histologically diagnosed in one of the authors practice (DB) over 4 years

Benign moles (including congenital naevi, intradermal naevi, blue naevus,etc) Viral warts Molloscum contagiosum Seborrhoeic keratosis Dermatofibroma Pyogenic granuloma Sebaceous cyst Skin tag Sebaceous gland hyperplasia Haemangioma (including cherry angiomas)

Melanoma 4%

SCC 25%

12 64

184

BCC 71%

BCC

SCC

Melanoma

45  Cancer and Pre-Cancer of the Skin

399 Primary care surgical association

Management of New or Changing Skin Lesions Lesion Pigmented

Non-pigmented

Confident, clinic, named diagnosis; eg: Benign mole, seborrhoeic keratosis, haemangioma, etc

Confident, clinical, named diagnosis; eg: viral wart molluscum, intradermal naevus, BCC, actinic keratosis, dermatofibroma, etc.

Suspicious features

Treat and advise as clinically indicated

Treat and advise as clinically indicated Dermatoscopy with training and experience

Low level of suspicion

Benign

No dermatoscopy available

Suspicious features

* Biopsy with 2mm border or urgently refer

Follow up in 3 months with photos (this only applies to flat moles) or refer

Reassure

Invasive melanoma

Refer to MDT

In situ melanoma

* Further excision of 5mm around the scar down to deep fat or refer

Dysplastic Naevus

Check all moles annually and consider mole mapping

NMSC

Treat and advise as clinically indicated or referral

Benign

No more treatment necessary

*Only doctors with experience in skin surgery should biopsy or excise

Fig. 45.2  PCSA algorithm on suspicious skin lesions

Another warning sign for skin cancer is the “NFG sign”. This stands for new, firm and growing. If a lesion shows these 3 signs it should be viewed with suspicion. The term “malignant melanoma” is no longer used. “Melanoma” is sufficient to describe this type of tumour as all melanomas are malignant. 90% of invasive melanomas arise in the skin, 5%

in the eye and the remainder in a variety of sites including the vulva (0.5%), nasal cavity (0.4%) and the anus (0.2%) according to the Nation Cancer Registry Ireland. Dermoscopy is extremely useful in making a diagnosis and differential diagnosis of unusual skin lesions but requires extra training. One study indicated that GPs who used dermoscopy after a

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fastest rising, preventable cancer in Ireland [3]. By 2040, it is estimated that there will be 33,000 Babies and children: Almost never cases of skin cancer diagnosed each year in Teenagers: Usually benign Ireland. Adults 30 years: Suspicions only 9% of all skin cancers. There were 968 cases Adults >40 years: Probably malignant and 159 deaths per year from melanoma in Adults >50 years: Usually malignant Ireland between 2012 and 2014. There are significantly more deaths in Ireland from melanoma 1 day training course were able to increase their than from cervical cancer (156 v 96  in 2014) sensitivity for detecting melanoma by 25% [1]. (Table  45.3). In 2014 melanomas breeched the Dermoscopy is not optional for any doctor who 1000 cases per year mark in Ireland (1041 cases has a special interest in skin lesion recognition to be exact) which means melanomas have almost trebled in the last 20 years. and skin cancer detection. On the other hand, NMSCs are the most comArtificial intelligence (AI) and deep-learning algorithms using machine learning may well mon cancer in Ireland and they represent almost completely change the way we screen for and one-third of all invasive cancers. While deaths diagnose skin cancer in the near future. Such from NMSCs are rare, they still account for algorithms are already showing evidence of approximately one-third (30%) of all skin cancer ­outperforming humans on specific tasks such as deaths in Ireland between 2012 and 2014. NMSC image recognition in radiology, self-driving cars, cause a huge burden of disease, can cause considin drones and soon in the diagnosis of some can- erable morbidity and are a huge drain on precious cers [2]. Apps are already available for smart- resources in health services. Dividing skin lesions into pigmented and non-­ phones which can help individuals track their moles looking for change over time (e.g. pigmented lesions can be helpful, since most melanomas are pigmented and most non-­ “Miiskin” or “SkinVision”). Most people have developed all their moles by melanoma skin cancers are non-pigmented. the time they are 40. A new mole after this age is However, a small percentage of melanomas can more suspicious, and the older the patient, the have no pigment (amelanotic) (Fig. 45.3) and can more suspicious a new mole is (Table  45.2). In be easily confused with benign lesions such as a the elderly it can be sometimes difficult to tell the pyogenic granuloma or with non-melanoma skin difference between a suspicious mole and a seb- cancers. Conversely many benign skin lesions orrhoeic keratosis but dermocopy in trained such as naevi (moles), seborrhoeic keratosis, dermatofibroma and some basal cell carcinomas can hands can help. be pigmented. Atypical looking seborrhoeic keratosis should be referred to a skilled dermoscopist or biopsied to rule out a melanoma (Fig. 45.2 Epidemiology 45.4a, b; Table 45.4). Non-pigmented (amelanonic) melanomas There is a significant increase in the incidence of skin cancer worldwide For instance, in Ireland tend to be larger, deeper and have a worse progthere are approximately 11,000 cases diagnosed nosis than pigmented melanomas, probably every year, with four people dying every week as because of delay in presentation and treatment a result of skin cancer. Incidence rates of non-­ (Fig. 45.5a, b). One small study in primary care melanoma skin cancers (NMSC) have risen by showed that almost a quarter (23%) of all inva31% in males and 27% in females in the last sive melanomas had little or no pigment [4]. Most skin cancers occur as a result of exces10  years (2005–2014) and rates for melanoma have increased by 73% in men and 23% in sive natural or artificial UV light from the sun or women during the same period, making it the sunbeds. Sudden bursts of excessive UVL on Table 45.2  When to suspect a melanoma when assessing a suspicious skin lesion according to age groups

45  Cancer and Pre-Cancer of the Skin

401

Table 45.3  Deaths Occuring (Number) by Sex, Cause of Death and Year in Ireland (2014)a

C00-D48 neoplasms C15 malignant neoplasm of oesophagus C16 malignant neoplasm of stomach C18 malignant neoplasm of colon C19 malignant neoplasm of rectosigmoid junction C20 malignant neoplasm of rectum C22 malignant neoplasm of liver and intrahepatic bile ducts C25 malignant neoplasm of pancreas C26 malignant neoplasm of other and ill-defined digestive organs C34 malignant neoplasm of bronchus and lung C43 malignant melanoma of skin C44 other malignant neoplasms of skin C50 malignant neoplasm of breast C51 malignant neoplasm of vulva C53 malignant neoplasm of cervix uteri C54 malignant neoplasm of corpus uteri C56 malignant neoplasm of ovary C64 malignant neoplasm of kidney, except renal pelvis C67 malignant neoplasm of bladder C71 malignant neoplasm of brain C80 malignant neoplasm without specification of site C85 other and unspecified types of non-Hodgkin’s lymphoma C90 multiple myeloma and malignant plasma cell neoplasms C92 myeloid leukaemia

Female 2014 4379 114 144 217 139 68 139 240 54 872 77 30 735 17 96 102 278 77 93 123 130 86 68 48

Male 2014 4839 270 225 282 169 101 187 274 73 1060 79 52 5 0 0 0 0 146 156 169 119 109 94 76

Both sexes 2014 9218 384 369 499 308 169 326 514 127 1932 156 82 740 17 96 102 278 223 249 292 249 195 162 124

From www.cso.ie and www.ncri.ie

a

skin that is not accustomed to it, resulting in blistering sunburn is one of the major risk factors for melanoma. Lower levels of UVL exposure over many years is a major risk factor for non-­ melanoma skin cancer which are more common on exposed sites of the body. Recent studies have suggested that increasing cumulative doses of hydrochlorothiazide, which is commonly used as a diuretic and antihypertensive, may cause an increase in NMSCs possibly as a result of its photosensitizing action [5].

45.3 A  lgorithms for Skin Cancer Detection

Fig. 45.3  An amelanotic nodular melanoma 3.9mm deep present for 2 years on the left arm in a 52-year-old female. The patient died 9 months later from metastatic disease

Various algorithms have been devised to assist in the clinical examination of suspicious pigmented skin lesions, including the US based “ABCD rule” (Table  45.5; Figs.  45.6 and 45.7), the UK

D. Buckley

402

a

b

Fig. 45.4 (a) Melanoma (SSM) on the low back in a man with many of seborrhoeic keratosis. This was an “ugly duckling”. (b) Close up of the same melanoma Table 45.4  Biopsy of Suspected Skin Cancer Suspicious lesion

Raised

Shave biopsy

Flat

Pigmented and/or suspicious for melanoma

Large

One to two small punch biopsies (2 to 3 mm) of the most suspicious areas of the lesion

Small

Complete excision unless size precludes

NOTE: This decicion tree is designed to assist the physician but cannot replace the physician’s judgment and may not be applicable in all situations.

Ref: October 15, 2004 ◆ Volume 70, Number 8 www.aafp.org/afp American Family Physician Diagnosis and Treatment of Basal Cell and Squamous Cell Carcinomas

a

b

Fig. 45.5 (a) Amelanotic melanoma 7.1 mm deep. It was present for 12 months. (b) Same patient 6 years later

45  Cancer and Pre-Cancer of the Skin

based “Revised 7-point checklist” (Table  45.6), and the “ugly duckling” sign where a suspicious Table 45.5  ABCD rule for assessing the risk of a mole developing into a melanomas Asymmetry—the two halves of the area may differ in shape Border—the edges of the area may be irregular or blurred, and sometimes show notches Colour—this may be uneven. Different shades of black, brown and pink may be seen Diameter—most melanomas are at least 6 mm in diameter. Report any change in size, shape or diameter to your doctor

Normal

Melanoma

Symmetrical

Asymmetrical

Even Edge

Irregular

A. Symmetry

B. Border

403

lesion stands out as being different than any other moles on the body. However, these screening tests will fail to detect amelanomic melanomas and most NMSCs. While these screening tools may be useful for doctors and other health professionals, they are not suitable for the general public as the terms are difficult to understand. The “Buckley 4 point skin cancer check list” screens for all skin cancers, both NMSCs and melanomas (pigmented and non-pigmented) (Table  45.7). This incorporates the ‘‘ugly duckling sign” which is a very useful aid in diagnosis of melanomas and NMSCs. It encourages the public to look for new or changing moles and skin lesions (sores or growths). This screening tool puts the warning signs in a logical sequence and includes only commonly used, easily understood terms  =  A new mole or growth that is changing (in size, shape or colour), looks different from any other mole or growth on the skin and is sore or tender. A useful mnemonic to help remember these warning signs is: “New Cancers Do Show”. A mole or growth that shows any one of these four warning signs has to be viewed with suspicion and the more warning signs that are found, the greater the chance that it is a skin cancer. Table 45.6  Revised 7-point checklist for assessing risk of melanoma

C. Colour One shade

>1 shades

6mm

D. Diameter

Fig. 45.6  ABCD rule for diagnosing melanoma

Suspect melanoma if there are 1 or more major signs in a mole: 1. Change in size (diameter or height getting bigger) 2. Change in shape (notched or ragged border) 3. Change in color (2 or more irregular colours including white) 3 or 4 minor signs without a major sign can also indicate a need to biopsy suspicious moles: 1. Inflammation 2. Crusting or bleeding 3. Sensory change (itch or soreness) 4. Diameter (≥7 mm) (but melanomas can be as small as 3 mm)

Fig. 45.7  Evolution of a mole: Change in size

Day 1.

2 Months.

4 months.

6 months.

D. Buckley

404 Table 45.7  The Buckley 4 point Skin Cancer Check List These are the warning signs that a lesion (a growth, a sore, a freckle or a mole) that is present for more than 6–12 weeks may be turning cancerous: A useful mnemonic to help remember these warning signs is: “New Cancers Do Show” • New—A new growth, sore, freckle or mole especially if you are older than 40 years • Changing—A growth, sore, freckle or mole that is changing in size, shape or colour over the past few months • Different—A growth, sore, freckle or mole that looks, feels or behaves different than any other growth, sore or mole on the body (the “ugly duckling”) • Sore—A growth, sore, freckle or mole that is sore, tender to touch, bleeding or itchy and will not heal after 6–12 weeks If a growth, sore, freckle or mole shows one or more of these warning signs it should be checked by your general practitioner. The more warning signs, the greater the risk of skin cancer. Early detection saves lives!

Once a suspicious skin lesion is detected it should be examined by a doctor (GP or dermatologist) trained in dermoscopy and a decision to biopsy, refer, observe or reassure can then be made. The desire not to miss a melanoma has to be balanced by the need to reduce unnecessary excisions. The exact type of skin cancer and definitive management plan can only be decided after a histological diagnosis is made (Fig. 45.8: PCSA management of NMSC). Lesions suspicious of melanoma should be referred urgently to a pigmented lesion clinic. Other suspicious skin lesions may be biopsied in primary care provided the GP has training and experience in lesion recognition and skin surgery. If a skin cancer needs to be referred to a plastic surgeon or dermatological surgeon, sending clinical and dermoscopic photographs with a detailed history and biopsy results should speed up the referral process and the pathway to definitive treatment in most cases.

45.4 Skin Biopsy Punch and shavse biopsies are a quick and easy way to diagnose many skin lesions (Table 45.4). However, they are not suitable for lesions suspicious of melanoma, whether pigmented or not. In this situation it is best to remove the whole lesion with a 2 mm border of clear skin all around and a generous cuff of subcutaneous fat. The NCCP and NICE guidelines currently recommend that these excisions should only be carried out in a specialist referral centre such as a Pigmented Lesion Clinic or a plastic surgery clinic. With the exception of lentigo maligna, a punch biopsy is not recommended for lesions suspicious of melanoma, as the biopsy may be taken from an area that may not be representative of the whole lesion and the melanoma may be missed. The Australian and New Zeland melanoma guidelines suggest taking multiple punch biopsies from the most suspicious areas of a lesion as judged by dermoscopy where the whole lesion cannot be easily removed and the chances of a melanoma is low but a definitive diagnosis is required (e.g. possible solar lentigo or a seborrhoeic keratosis, pigmented AK or lentigo maligna). When taking a skin biopsy, it is essential to include the patient’s name, date of birth, address, skin type, gender, date biopsy was taken and the anatomical location of the lesion. It is recommended to specify the type of biopsy being taken (incision, excision, punch, shave, curettage, etc), the size of the lesion and the clinical margins if a complete excision is undertaken. If orientation sutures are used on the specimen, there location should be included on the histopathology form. It is important to give a brief history and clinical description of the lesion along with a differential diagnosis. If the GP cannot make a reasonable clinical diagnosis and differential diagnosis it may be better to refer the patient with the lesion intact to a colleague with experience in lesion recognition, dermoscopy and skin surgery.

45  Cancer and Pre-Cancer of the Skin

405

Primary Care Surgical Association. Guidelines on the management of non-melanoma skin cancers (NMSC) Low risk NMSCs *

Refer all if no skin surgery training and experience. (Level 1 community surgery)

Intermediate risk NMSCs **

Excise if basic skin surgery training and experience or refer (Level 2)

Treat or excise if advanced skin cancer training and experience or refer (Level 3)

High risk NMSCs ***

Referral to a plastic surgeon or a Moh’s surgeon.

* Low risk NMSCs = tumours 10 mm Induration Inflammation Ulceration Bleeding Rapid expansion Tender on palpitation Rapid recurrence after treatment (e.g. 2 months) Persistence post treatment Immunosuppressed patients Organ transplant patients High risk areas: lip, ear, dorsum of the hand

clinical lesions simultaneously. Field treatments can be carried out with various topical agents such as 5-fluorouacil (“Efudex®”), Diclofenac gel (“Solaraze®”), imiquimod 3% (“Zyclara®”) or photodynamic theraphy (PDT). These treatments can cause considerable and unpredictable irritation and soreness and are best used under the supervision of a doctor with experience in topical field therapies as careful patient counselling is required pre-treatment. Some doctors treat the larger, thicker, more hyperkeratotic AKs first with cryosurgery and then treat the whole field with a field based topical treatment once the cryosurgery wound has healed. Alternatively, treating the field first with topical therapies and later the residual lesions with cryosurgery may also be successful. Unresponsive lesions should be biopsied or referred. Imiquimod is an immune modulator that regulates Tool-like receptor-7 induced cytokine production and its use has been approved for the treatment of AK (“Zyclara 3%®”) or Bowen’s disease, superficial BCC and genital warts (“Aldara 5%®”) (Table 45.11). “Aldara®” comes in tiny sachets and only one sachet should be used per application. A single-use sachet is sufficient to cover an area of 20 cm2. “Zyclara®” comes in similar size sachets but up to 2 sachets can be used per day. However, it is best to use only one and distribute its content carefully to reduce systemic reactions. It should be applied once daily before bedtime to the area affected by multiple AKs (“the field”) and 2 sachets should be enough to cover the dorsum of both hands or the

Table 45.10  Topical treatment for actinic keratosis (AK), Bowen’s disease and superficial BCCs (sBCC) Treatment Diclofenac gel (“Solaraze®”) Imiquimod 3% (“Zyclara®”) Imiquimod 5% (“Aldara®”)

AK + + +

Bowen’s − − +

sBCC − − +

Duration of treatment 60–90 days 2 weeks on +2 weeks rest—Repeat once 4–12 weeks

5—Fluorouracil (“Efudex®”)

+

+

+

Photodynamic therapy (PDT)

+

+

+

2 weeks on +2 weeks rest—Repeat twice Once + repeat once after 7 days

Irritation −/+ ++ (variable) +++ (variable) ++ +/−

D. Buckley

408 Fig. 45.12 Treatment algorithm for actinic keratosis

Actinic Keratosis (AK)

Macular (flat) isolated AK

Hyperkeratotic AK

Cryosurgery

Paring & cryosurgery

Multiple AK = Field of cancerization

Suspicious AK – See Table 45.9

Topical field treatment* e.g. 5% 5-Fluorouracil. 3% Diclofenac sodium. 3% Imiquimod. PDT

Biopsy or refer if the AK is suspicious, does not clear with treatment or recurs quickly (within 2 months) PDT = photodynamic therapy * may be combined with paring and cryosurgery for isolated hyperkeratotic AK’s in the field. © Dr David Buckley 2016

oxygenase-­2 resulting in reduced prostaglandin synthesis [11]. Raised prostaglandins have been linked with sun damage and AKs [12]. “Solaraze Diagnosis Treatment protocol Repeat treatment cream®” can be useful for small superficial AKs Actinic 3 times a week for May need second and, unlike 5-fluorouracil or “Zyclara®”, it causes keratosis 4 weeks cycle very little irritation. However, it has to be applied Bowen’s 5 times a week for May need second twice a day for 3  months, may not clear larger, and sBCC 6 weeks cycle more hyperkeratotic AKs and relapse is not Lentigo 7 times a week for a uncommon. Occasionally patients can be allergic maligna 12 weeks to diclofenac and can develop local severe reacGenital 3 times a week up Until clearance of tion that may require stopping the medication. warts to 16 weeks visible warts a Ingenol mebutate (“Picato®”) is an extract of a not licensed for this use common plant, petty spurge or milk weed (Euphorbia peplus) which is grown in Australia. It forehead or the balding scalp. It is applied daily for is thought to work by causing rapid lesion necrosis 2 weeks followed by a 2 week rest period before and specific neutrophil-mediated, antibody-­ applying it again for a further 2 weeks. dependent cellular cytotoxicity. Only one tube Diclofenac (“Solaraze®”) is a nonsteroidal, should be used per day and it should be washed off anti-inflammatory drug that inhibits cyclo-­ after 6 hours. Great care is required to avoid getTable 45.11  Imiquimod 5% (‘‘Aldara®”) for treatment of actinic keratosis, Bowen’s disease, superficial BCCs (sBCC), lentigo maligna and genital warts

45  Cancer and Pre-Cancer of the Skin

a

409

b

Fig. 45.13 (a) Actinic keratosis before treatment with ingenol mebutate. (b) Same patients 6 days post treatment. Similar reactions might occur with 5-fluorouacil and imiquimod 3%

ting it into the eyes where it can be very irritating. The content of one tube covers a treatment area of 25 cm2 (e.g. 5 × 5 cm) which is equivalent to the area on the dorsum of one adult’s hand. It comes in 2 strengths (0.015% which should be applied to the face or scalp daily for 3  days or the 0.05% which can be used on the body daily for 2 days). Reactions tend to appear 3–4  days after the last application (Fig. 45.13a, b). In 2020 the European Medicine Agency withdrew “Picato” (ingenol mebutate), concluding that this medicine may increase the risk of skin cancer and that its risks outweigh its benefits. “Zyclara®” and “Picato®” can cause considerable, unpredictable irritation in some patients when used for field directed treatments of AKs and solar elastosis. The more severe the reaction the better the result but some patients may not be able to tolerate these treatments. Significant reactions that the patient hates, the physician loves to see as it means the treatment is working. It may be kinder to the patient to delay treatment until a quite time in the patient’s life when they have no major work or social engagements planned within the following 2 weeks post treatment. Photodynamic therapy (PDT) involves applying aminolevulinic acid (ALA) or methyl aminolevulinic (MAL) cream under occlusion for

3 hours to the lesion or area being treated. This is a pro-drug that is intracellularly metabolised to protoporphyrin IX, a photosensitising molecule. When this is activated by exposure to light from an LED lamp (for 9–10  minutes usually under local anaesthetic) or daylight, free radicals and reactive oxygen species are generated which are cytotoxic and selectively kill the pre-cancer (AK’s or Bowens disease) or cancer cells such as superficial BCCs [13]. While the treatment itself may be painful in some patients, there is little post-operative irritation and usually excellent cosmetic results. Aminolevulinic acid (ALA and MAL) cream is very expensive and the success rate when treating Bowen’s disease and superficial BCCs may not be as good as other methods used to treat these lesions [14]. 5-fluorouracil (“Efudex®”) is a cytotoxic agent that can selectively destroy certain cancer or precancerous cells. It is used for the topical t­ reatment of superficial pre-malignant and malignant skin lesions including AKs, Bowen’s disease and superficial basal-cell carcinoma. A recent study published in the New England Journal of Medicine showed 74.7% of patients treated with 5-fluorouracil (twice a day × 1  month) cleared their AKs 12 months from the end of therapy versus 53.9% who received imiquimod, 37.7% given

410

MAL-PDT and 28.9% treated with ingenol mebutate [15]. All patients with AKs, solar elastosis (skin thinning form excessive UV exposure) or skin cancer should be advised to protect their skin from ultraviolet light with the careful use of clothing, a broadbrimmed hat and high factor sunblocks such as SPF 30 or greater. This degree of photo-protection will put the patient at risk of vitamin D deficiency so these patients should take a vitamin D supplement daily (800–2000 IU a day) especially in the winter provided there are no contraindications (e.g. renal stones, renal failure, hypercalcaemia, etc).

D. Buckley

Bowen’s disease (also known as intraepidermal SCC or SCC in-situ) is quite common on the face and lower legs, especially in women. They are generally macular (flat), red and slightly scaly but usually there is no ulceration or bleeding (Fig. 45.14). They may resemble an actinic keratosis or a superficial BCC or even an SCC.  Dermoscopy may help in making the diagnosis but a biopsy should always be taken before definitive treatment. For larger lesions (>10 mm) two or more biopsies may be necessary and the leading edge is more likely to con-

firm the diagnosis rather than taking biopsies from the centre of the lesion. Although considered low risk, 3–5% of Bowen’s disease will progress to SCC so it is important to treat them in the majority of patients. Up to 10% of Bowen’s disease on the genitalia will progress to SCC.  However, if they are found in a very frail elderly patient in a difficult to treat site (e.g. lower legs), it might be more appropriate to keep them under observation rather that treat them. If they show signs of progressing to an SCC (becoming ulcerated or nodular) curative treatment may have to be considered. Because they are superficial, Bowen’s disease may respond to topical treatment such as 5-­fluorouracil (“Efudex®”) (Fig. 45.15) or 5% imiquimod (Aldara®) (Tables 45.10 and 45.11). However, this is a slow, and potentially painful treatment that requires a coordinated, well-­ motivated patient, as the whole treatment can take weeks or months of nightly treatment. This may be difficult or impossible in an elderly patient, living alone with a physical or mental disability. This treatment can also be distressing in a younger patient who is working as they may have to put up with an unsightly, scabbing lesion for 6–12  weeks during the treatment phase which can be distressing, particularly if the lesion is on the face, hands or lower legs.

Fig. 45.14  Bowen’s disease (SCC in-situ) on the cheek

Fig. 45.15  Bowen’s disease before treatment with 5-fluorouracil (“Efudex®”)

45.6 Bowen’s Disease (SCC In Situ)

45  Cancer and Pre-Cancer of the Skin

Small lesions in easily accessible sites can be excised with a 4 mm border but this may prove difficult especially in the lower leg or the face and may represent over treatment of a superficial, pre-cancerous lesion. Cryosurgery is very successful for treating Bowen’s disease when carried out under experienced hands. It usually requires a 30 second freeze and one freeze-thaw cycle. This can be painful and is best given under local anaesthetic. The complete lesion and 4 mm of clear, unaffected surrounding skin should be frozen as fast as possible and once the ice-ball reaches the treatment borders, it should be maintained by intermittent bursts of liquid nitrogen spray for 30 seconds. This causes considerable swelling, oedema and crusting which can take 2–4  weeks to heal (Fig. 45.16a, b). Cryosurgery is not suitable for larger lesions (>10–20  mm) and is not recommended in the lower leg as healing time can be extremely slow in this area (see Chap. 58). In experienced hands, curettage followed by cautery (usually mono-polar diathermy) is a very effective treatment for treating Bowen’s disease if the procedure is undertaken three times (the cauterised area is curetted and again cauterised twice more in a single session). The material from the first curettage is sent for histology, the subsequent material curetted after cautery is of

a

411

no diagnostic use; it just acts to provide a deeper clearance of the superficial lesion.

45.7 S  quamous Cell Carcinomas (SCCs) Some SCCs arise de nouveau from apparently normal skin. Others develop from a pre-existing actinic keratosis (Fig. 45.17a, b), from an area of Bowen’s disease or from an area of chronic inflammation or ulceration (e.g. a leg ulcer that fails to heal despite appropriate management). SCCs are usually red, scaly and may have some superficial ulceration (Fig. 45.18). They can be flat or nodular (Fig. 45.19). They are usually raised, growing and tender. Diagnosis is confirmed by biopsy such as a punch biopsy or an incision or excision biopsy. SCCs may occur on all areas of the body including the mucous membranes and genitals, but are most common in areas frequently exposed to the sun, such as the rim of the ear, lower lip, face, balding scalp, neck, dorsum of the hands, or on the arms and legs. The majority of SCCs are low risk but approximately 2–5% of SCCs metastasize. The aggressiveness of an SCC is described by its degree of differentiation. A mildly differentiated SCC is considered low risk of metastases, a moderately

b

Fig. 45.16 (a) Bowen’s disease before treatment with cryosurgery; (b) same patient immediately after treatment

D. Buckley

412

a

b

Fig. 45.17 (a) Patient with erosive pustular dermatosis of the scalp with underlying Bowen’s disease and SCC; (b) same patient after scab removal

Fig. 45.18  SCC and actinic keratosis on the scalp of a fisherman

differentiated SCC is considered medium risk and a poorly differentiated SCC is considered high risk and aggressive. High risk SCC tumours may also have perineural or vascular invasion which indicates an even greater risk of metastasis. Larger deeper tumours, especially those tethered to underlying structures are also considered high risk. SCCs involving the lip (mostly the lower lip) and ear tend to metastases early. All high risk SCCs should be referred to a plastic surgeon or dermatological surgeon without delay (Table  45.12). Draining lymph nodes should be palpitated and their presence or absence should be recorded at the time of presentation or referral (Fig. 45.20).

Fig. 45.19  Two SCCs (moderately differentiated) on the right cheek

Treatment is usually with excision including a 4 mm border of clear skin all around for low risk SCCs. High risk SCCs may need much wider margins and adjunct radiotherapy.

45  Cancer and Pre-Cancer of the Skin Table 45.12  High risk NMSCs Recurrent tumours NMSC in areas where there are cosmetic concerns Large tumours (>10 mm on face or > 30 mm on body) Large tumours on the vertex of the scalp or below the knees Tumours involving the naso labial folds or the pre or postauricular folds Poorly differentiated SCCs Deeply invasive NMSCs (>4 mm deep) especially those involving the lips, ears, nose or eyelids Tumours with indeterminate margins or tethered to underlying structures (e.g. Morphoeic BCCs) Immunosuppressed patients Rare aggressive tumours (e.g. Acantholytic, spindle or desmoplastic SCCs, Merkel tumours or dermatofibrosarcoma protuberans) Where there is a risk of metastatic spread (e.g. Regional lymph nodes enlarged) ≤1 mm histological clearence

413

SCCs may lurk under a cutaneous horn, especially in the elderly so suspicion should be high if there is any erythrema or thickening of the base of a cutaneous horn. It is best to remove them by deep shave or excision biopsy and always send the specimen for histological diagnosis (Fig. 45.21). Keratoacanthoma (KA) usually appears as a nodular lesion with a central keratin plug in the light exposed areas in the elderly that can grow rapidly within 4–6 weeks (Fig. 45.22). The natural history of a KA is that it may regress spontaneously over 3 or 6  months. However, it can sometimes be difficult if not impossible to tell the difference between a KA and a well differentiated SCC both clinically and histopathologically (Fig. 45.23a–c). When sending a possible KA for histology it is best to send the whole lesion and clearly indicate on the pathology form that the lesion grew rapidly and that you are considering a KA as well as an SCC in the differential. KAs

Fig. 45.20  Metastatic disease from an SCC

Fig. 45.21  Cutaneous horn on left temple. Histology showed a hyperkeratotic actinic keratosis

Small well differentiated SCCs may be treated with aggressive cryosurgery but this should only be carried out by doctors with extensive experience in this procedure. It involves freezing the debulked tumour and at least 4 mm of surrounding uninvolved skin under local anesthetic with liquid nitrogen spray under temperature control for 30 seconds and 2 freeze thaw cycles. This will cause considerable swelling and blistering but the lesion usually heals with an acceptable scar within 4–8 weeks.

Fig. 45.22  Keratoacanthoma (SCC/KA subtype) which grew to this size in 6 weeks

D. Buckley

414

a

b

c

Fig. 45.23 (a) Keratoacanthoma which grew to this size over 3 weeks. (b) Same patient 2 weeks later. (c) Same patient 9 weeks after the first photo. It was fully excised with a skin graft

are best considered a variant of SCC and should be treated by complete surgical excision including 4  mm of clear skin all round. Smaller KAs (10  mm), swelling or in severe cases even blisters or ulceration (Fig. 54.1). Healed areas may leave evidence of post-inflammatory hyperpigmentation. The key distinguishing feature and important clinical point is that petechiae and purpura are raised (palpable) and do not

© Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_54

503

504

D. Buckley

Table 54.1  List of some rare generalised forms of vasculitis some of which may have skin manifestation Cutaneous vasculitis Manly affects the skin but other organs may be involved (e.g. Henoch–Schönlein purpura, urticarial vasculitis, meningococcal septicaemia, drug induced vasculitis) Behçet’s syndrome Also known as Behçet’s disease, is an autoimmune condition which causes mouth ulcers, genital ulcers, skin problems and eye inflammation Giant cell arteritis (temporal arteritis) Giant cell arteritis causes severe inflammation in the large blood vessels, and commonly affects the arteries in the head that can cause headaches and rarely blindness Polyarteritis nodosa Polyarteritis nodosa (PAN) causes inflammation to medium-sized arteries of the GI tract and kidneys Takayasu arteritis Takayasu arteritis (TA) is a rare inflammatory disease that affects the large artery from the heart and its large branches, usually in younger women Kawasaki disease Kawasaki disease is quite a very rare condition which affects small and medium-sized arteries, usually in small children ( 5 years 60 g in adults

Table 56.2  Ways of reducing pain when giving local anaesthetic Local anaesthesia (LA), for skin surgery • Relax and reassure patient (Pre med) • Lie down • Consider topical anaesthesia • Consider a “Dermajet®” to numb the skin before inserting the needle • LA at room temp + without Adrenaline • If using adrenaline = buffer with sodium bicarbonate • Start with the smallest needle possible (e.g. 30 g) • Pressure on puncture site before inserting the needle • Ethyl chloride or light Cryo × 3 seconds. • Distract the patient • Inject slowly + subcutaneously + start proximally •C  onsider regional anaesthesia (ring block, post tib. block) • Wait till fully anaesthetized (3–5 min)

plain or 50 ml of 1% “Xylocaine®” with adrenaline can be used in a 70  kg adult (Table  56.3). There is no great advantage to stocking 2% or 0.5% lidocaine and it is safer and easier to calcu-

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Table 56.3  Local anaesthetic for local infiltration or peripheral nerve block

Name Lidocaine 1% (“Xylocaine ®”) Lidocaine 1% with adrenaline (epinephrine) 1:200,000 Bupivacainea (0.25%) (“Marcaine ®”) Bupivacainea (0.5%)

a

Max in 14 kg Max in child (approx. 70 kg 3 year old) (ml) (ml) 21 4

Max in 22 kg child (approx. 6 year old) (ml) 7

Description Amide

Onset (min) 2–10

Duration Strength (h) (mg/ml) 0.5–2 10

Max dose (mg/ kg) 3

Amide

2–10

2–4

7

49

10

15

Amide for local infiltration Amide for peripheral nerve block

10– 15

3–12

2.5

2

56

a

a

10– 30

5–15

5

1

14

a

a

10

Generally not recommended in children less than 12 years old

late the safe dose if only 1% is stocked. It is advisable to buy the lidocaine with adrenaline and lidocaine without adrenaline in different types of vials and store them in different locations to avoid errors. It is also safer to draw up LA in only 2 or 5 ml syringes to ensure you do not give too much, especially when injecting children. Local anaesthetic solution injected at body temperature produces significantly less pain than local anaesthetic injected which has been cooled in the fridge. Injecting very slowly and subcutaneously rather than intradermally will also reduce pain. Start injecting the area of the lesion that is closest to the origin of the sensory nerve supplying that site (e.g. proximal before distal injection). Regional nerve blocks such as a ring block, a posterior tibial block or an infraorbital block are often less painful than local infiltration in certain areas. When adrenaline is used in an LA, sodium metabisulphite or bisulphite is added by the manufacturers to prevent adrenaline oxidation. These chemicals increase the acidity of the LA and make the injection more painful. Adding 1 ml of 8.4% sodium bicarbonate for every 10 ml of lidocaine with adrenaline immediately prior to use

Table 56.4  Alkalinisation of local anaesthetic solutions

Anaesthetic solution Lidocaine 1 or 2% + adrenaline Bupivacaine 0.25 or 0.5% + Adrenaline

Volume of 8.4% sodium bicarbonate to be added to 20 mL 2 mL 0.1 mLa

The small volume of 8.4% sodium bicarbonate to be added requires great care as adding too much will cause precipitation. Discard any unused buffered LA immediately after use as it will not store

a

will raise the pH and make the administration of the local anaesthetic less painful. This is called ‘alkalinisation’ or ‘buffering’ of the solution. Sodium bicarbonate also shortens the onset and prolongs the intensity and the duration of the block. It also shortens the shelf life of the LA and should only be added immediately prior to use and any unused mixed solution should be discarded immediately (Table 56.4). The maximum amount of lidocaine with adrenaline should be reduced in patients with severe ischaemic heart disease, arrhythmias, thyrotoxicosis, unstable hypertension, uncontrolled diabetes, epilepsy and porphyria. According to the Summary of Product Characteristics, lidocaine should be used with caution with certain drugs

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such as cimetidine, betablockers, monoamine-­ oxidase inhibitors, tricyclic antidepressants, phenothiazines and butyrophenones. The onset of action from 1% lidocaine with or without adrenaline is usually approximately 3–5 min and is up to 10 min when using a ring block anaesthetic. Adding adrenaline considerably prolongs the duration of action (up to 7 h) and will reduce bleeding. Local anaesthetic with adrenaline should be used with caution in fingers, toes, the penis, nasal tip and ear lobes and for ring block anaesthesia, especially in patients with PVD or diabetes. The effectiveness of LA may be reduced and the absorption increased when injecting into infected or inflamed areas. Although injecting intradermally is more painful, the onset of action is far more rapid. LA can be used to hydrodissect the skin from the cyst wall when preparing to remove a sebaceous cyst or to raise the skin off superficial fascia to protect vital structures in facial work. Vasoconstriction after infiltration of the local anaesthetic is common as a result of the pressure effect on the adjacent blood vessels and the vasoconstriction effect of adrenaline. This may make the outline of the lesion or rash to be biopsied or removed more difficult to see. For this reason, it is advisable to mark out the outline of the lesion and the safe margins for excision or biopsy after cleaning the skin thoroughly and before infiltrating with local anaesthetic.

Table 56.5  Signs and symptoms of systemic lidocaine toxicity include • Severe numbness or tingling especially around the mouth • Dizziness and drowsiness • Tinnitus (ringing in the ears) • Slurred speech • Metallic taste in mouth • Mental status change or loss of consciousness • Muscle twitching • Seizures • Arrhythmia (tachycardia or bradycardia) • Coma • Respiratory arrest • Cardiac arrest

8. Cardiac arrest 7. Respiratory arrest 6. Coma 5. Seizures 4. Muscular spasm 3. Tinnitus or auditory hallucination 2. Paresthesias of the mouth and tongue 1. Drowsy

56.4 Toxicity, Anaphalylaxis and Fainting Local anaesthetic is very safe. However, there is a very small risk of toxicity (Table  56.5 and Fig. 56.1) or anaphylaxis to amide anaesthetics or some of the additives, so full resuscitation equipment should be on hand at all times. Always aspirate before injecting to ensure the LA is not injected into a vein or artery. A more likely reaction is a vasovagal syncope (fainting) episode as a result of the injection, especially in children

Fig. 56.1  Progression of local anesthetic toxicity

and young adults. Always lie the patient down before infiltrating with local anaesthetic and performing surgery and if a patient feels faint they should be placed on a couch with their head down and feet up for at least 10 min. Always consider LA toxicity if the patient becomes unwell following procedures under LA (Table 56.6).

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Table 56.6  Distinguishing anaphylaxis from fainting (vasovagal reaction) and lidocaine (“Xylocaine®”) toxicity Onset Skin Respiratory Cardiovascular Neurological

Treatment

Fainting Immediate (1–10 min) Pale Normal to deep breaths Bradycardia Weak, faint or loss of consciousness. Feels better when lying flat

Anaphylaxis Delayed (5–30 min) Flushed, swelling urticaria Wheeze Tachycardia Weak, faint or loss of consciousness. Little response to lying flat.

Lie flat, head down, legs up

Lie flat, head down, legs up IV fluids—crystalloid IM adrenaline 1:1000 – Adult = 0.5 ml – Child 6–12 yo = 0.3 ml – Child < 6 yo = 0.15 ml

56.5 Conclusion Topical or local anaesthetic are vital when investigating and/or treating some skin conditions. It ensures the patient is comfortable and relaxed which will make the procedure more tolerable and successful for everyone concerned. However, giving an injection of local anaesthetic can itself be painful and the doctor or nurse should use the correct product, the smallest needle possible and a perfect technique when injection local anaes-

Lidocaine toxicity Delayed (10 min–2 h) – Slow respirations Arrhythmias – Tingling lips – Tinnitus – Blurred vision – Slurred speech – Muscle twitching – Seizures – Lie flat – I.V. fluids— crystalloids – I.V. Diazepam for seizures – Consider I.V. lipid emulsion 20%

thetic. In addition, great care needs to be taken to avoid complications from giving a local anaesthetic, from fainting to an allergic reaction.

References 1. Buckley D. Evaluation of local anaesthetic infiltration for cryosurgery of hand warts: a prospective comparative study. Ir J Med Sci. 2016;185(3):561–4. https:// doi.org/10.1007/s11845-015-1301-x. 2. Buckley D. Cryosurgery treatment of plantar warts in general practice. Ir Med J. 2000;93(5):140–3.

Simple Skin Surgery

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57.1 Key Points

57.3 Introduction

–– Some conditions may need surgical intervention for either diagnosis, treatment or both. –– Most skin surgery errors are made with the pen, not the knife. Carefully patient and lesion selection plus marking the lesion and borders with ink before surgery is very important. –– Simple techniques such as shave, punch or snip biopsy and curettage are easy to carry out in general practice. –– All tissue removed from the skin should be sent for histology. –– Disposable instruments are the easiest way to ensure a safe supply of instruments.

While many skin problems seen in primary care can be easily diagnosed clinically and managed with simple topical or oral therapies, some conditions may need surgical intervention for either diagnosis, treatment or both. Important attributes for any surgeon are competent clinical judgement as well as the technical skills for operating. Once you have started an operation and made your first incision there is no going back. So give careful consideration to the following points:

57.2 What to Tell the Patient –– Simple surgical procedures in primary care are safe, convenient and a lot less expensive that when carried out in hospital. –– Side effects are rare but bleeding and infection can sometimes occur. –– Please do not drive immediately after a surgical procedure even if performed under local anaesthetic. –– You will need to sign a consent form.

• • • • • •

Do I know what the lesion is? Do I need to operate? Am I experienced enough to do it? Do I have the right equipment? Have I got enough help? Have I got enough time?

Some surgical techniques such as punch biopsy or cryosurgery can be carried out easily in primary care. Patients and staff safety is paramount and a doctor must have a way of insuring that all required instruments are properly decontaminated either by only having disposable

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland © Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_57

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instruments or having an effective decontamination protocol.

57.4 Instruments The easiest way to ensure a reliable source of safe, sound instruments is by using disposable instruments. While these might seem expensive initially, they are probably more cost effective, given the time and equipment that is required to decontaminate reusable surgical instruments in primary care. The quality and range of instruments available when using disposables is not as good as re-usable instruments but disposables are adequate for small procedures such as biopsies. Another option for decontamination of reusable surgical instruments is to get them decontaminated in a Central Sterile Supply Department (CSSD) in the local hospital if that facility is available. For in-house decontamination in a GP surgery the minimum standard is a safe method of cleansing the instruments (e.g. a washer/disinfector) and a class B autoclave. It is vital to ensure that all doctors, nurses, administration staff, and cleaners are vaccinated against Hepatitis B and are aware of the practice guidelines for needle stick injuries, if surgery is to be carried out in the practice (Table 57.1). Other pre-requisites for simple skin surgery is a clean procedure room, good lighting and magnification, protected time and an assistant, if possible. Consent and proper surgical record ­ keeping is vital for medico-legal reasons (See sample consent form, Chap. 66). Table 57.1  Essential documents required if carrying out surgery in a practice –  Health and Safety Statement – Hepatitis B vaccination status of all personnel working in the surgery –  Guidelines for needle stick injuries – Guidelines for decontamination of reusable surgical instruments –  Hand hygiene protocol –  Significant event analysis record –  Infection control policy –  Guidelines on anticoagulants

57.5 Histology All tissue removed from the skin should be sent for histology. Specimen should be placed in 10% formalin and the bottle should be labelled in handwriting with the patient’s name, date of birth, location of the specimen and type of biopsy taken. It is important to give the pathologist as much information as possible when sending histology. The minimum required is the name, address, date of birth and sex of the patient. The size of the lesion, the location of the biopsy site and the type of biopsy taken (punch, shave, incision, excision, curettage, etc.) are also important to include in the form. A brief history of the lesion or rash with a clinical diagnosis and differential diagnosis is important to convey to the pathologist. If you cannot make a reasonable assessment of what the rash or lesion might be on clinical grounds alone, it may be better to refer the patient to a colleague with more experience in dermatology who can give the pathologist a reasonable differential diagnosis to work from. Relevant past medical history (e.g. past history of skin cancer) and previous histology reports should be included if available. If possible all skin specimens should be sent to a pathologist with an interest in dermatohistopathology. Tumors are easier to intrepid than rashes. Vague, non specific rashes may not be the best ones to biopsy as the histological report may also be vague and non-specific. On the other hand, certain rashes have quite characteristic histological features and the pathologist should be able to confirm the diagnosis if the clinician asks if the biopsy shows features of a specific condition (e.g. lupus erythematosus, lichen planus, dermatitis herpetiformis, vasculitis, fungal infection of the skin, etc.). Histopathology may help make a diagnosis such as eczema or dermatitis but may not be able to distinguish the exact type (atopic, allergic contact, irritant, etc.) or the cause. Histopathologists may sometimes find it difficult to differentiate between different skin tumours such as Bowen’s disease from SCC or a dysplastic nevus from a melanoma in situ. Getting a second histological opinion can be useful in this situation. There must be a robust method of tracking histology to ensure that the results come back in a

57  Simple Skin Surgery Table 57.2 The biopsy pathway

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skin

Decision to perform a biopsy Reasons for biopsy and risks are discussed with patient Biopsy details are determined: type and size, number of biopsies, body site and location within lesion as determined by dermoscopy if available Labelling of appropriate transport media/container (usually Formulin 10%) and completion of the requisition form with patient’s name, date of birth, type of biopsy, location, diagnosis and differential diagnosis Biopsy specimen is obtained and placed in the correctly labelled container Transportation of biopsy specimen and requisition form to dermatopathology lab Clinician keeps a record of all specimens sent to lab and check in two weeks that all results have come back Patient given written instructions on post-operative wound care and to phone back in two weeks for results Accurate processing of the specimen A pathology report is generated and transmitted to the clinician The clinician determines the mode of action/therapy Communication of the result and mode of action/therapy to the patient (and other clinicians if necessary) Treatment of disease based on the pathology report *Ref: Adapted from JAAD 2016, 74: 19-25

timely fashion and the patient is informed of the results and advised if any further treatment is necessary (Table 57.2). Precise measurements of this size and location of the legion, with drawings or diagrams if possible, should be taken prior to surgery. A photo is even better at recording the location and size of the legion in case further treatment or referral is required.

57.6 Bleeding and Infection

Fig. 57.1  Large haematoma in the breast post punch biopsy in a patient on asprin and dipyridamole

All surgery carries risks. The most common is bleeding and infection. Bleeding is more common if the patient has a coagulopathy (rare) or is on anticoagulants (common) (Fig. 57.1). If possible, anticoagulants should be stopped before

surgery but the surgeon may have consult with the doctor who prescribed the anticoagulants to ensure that it is safe to stop (Table  57.3 and Chap. 66 PIL on “Anticoagulants and surgery”). Patients on warfarin can have low risk c­ utaneous

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Table 57.3  PCSA Guidelines on anticoagulants and cutaneous surgery in the community Risks to patient from stopping anticoagulation or antiplatelet drugs include stroke, DVT/PE, MI, or even death. The risk of skin surgery bleeding may be inconvenient, can result in a haematoma or an abscess and may jeopardise a flap or graft but is rarely serious or life threatening Stopping anticoagulants that have been prescribed for strong clinical indications is therefore rarely justifiable Meticulous operative technique is always required to minimise the risk of bleeding with cutaneous surgery but, even so, bleeding problems can occur. Excessive bleeding during surgery usually responds to electrosurgery or vessel tying, followed by a pressure dressing and patient rest and elevation of the operative site where possible. However, some agents can cause prolonged oozing after the local anaesthetic (LA) wears off, or for several days post-op, even if excellent haemostasis is achieved intra-operatively. For this reason, reducing this risk by postponing surgery, altering the choice of procedure or repair, or sometimes withholding medications may be prudent. The use of LA without adrenaline may be considered so as to avoid delayed bleeding problems General tips to reduce risk of bleeding •  Consider postponing surgery until risk factor(s) can be removed or optimised • Choose safer procedure type if possible or alternative if sufficiently effective e.g. radiotherapy, cryosurgery or non-surgical options such as Aldara or Efudix. • Use meticulous surgical techniques and consider electrical surgery, radiosurgery, aluminium chloride or tranexamic acid for injection (“Cyklokapron®” applied topically on a gauze to control bleeding). • For open wounds consider an alginate dressing to adsorb exudates which may aid haemostasis • Elevate and compress post-op • Consider referral to a more experienced operator • Consider admitting the patient overnight post-surgery Risk factors for significant post-operative bleeding events • Previous post-op bleeding episode • Unable or unwilling to rest post-op • Bleeding tendency (anticoagulants, Haemophilia, low platelets 65 Risk Stratification of Community Surgery Procedures Low Risk Procedures – Curettage – Punch biopsy – Incisional biopsy – scar length 5 mm it is advisable to infiltrate with local anaesthetic using a 30G needle under the lesion before paring and freezing. However, avoid a local anaesthetic with adrenaline on or near the fingers, toes, the tops of the nose and earlobe, as it can cause vaso-constriction Always warn patients about post-operative swelling, pain and possible serous or haemorrhagic blistering. Instruct them to burst the blister with a sterile pin and squeeze out the fluid. They should bathe the area in some dilute “Dettol” and apply an antiseptic cream such as “Savlon” cream and dress with a dry dressing Oral analgesics such as paracetamol or ibuprofen may be given before or immediately after cryosurgery and continued as required Treat just one hand per session when treating bilateral hand warts. If there are numerous hand warts, treat only half of one hand or less per session as postoperative pain and swelling can be troublesome. As a general rule, treat a maximum of 4–8 warts per session When treating verrucae treat one foot per session. In addition, treat only the fore foot or the hind foot (not both) per treatment session, as this will allow the patient to walk on either the heel or the toe post-operatively. Spraying down a suitably sized auroscope cone can improve the success rate and reduce the complications when treating verrucae. Avoid using the auroscope cones on the face or hands, as scarring may be a problem Any cryosurgery probes or tips that touch the patients skin should be sterilised between patients. If you are using the cotton bud or dip probe technique, decant a small amount of liquid nitrogen into a polystyrene cup and dip into this. Discard the cotton bud, the liquid nitrogen and the polystyrene cup after treating each patient, as viruses can survive in liquid nitrogen If you are a beginner in cryosurgery, confine your treatments to warts and verrucae for the first year until you get used to handling the equipment, the patient and the tissues. It is advisable to get training and supervision from an experienced cryosurgeon before treating patients alone in your surgery

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Children under the age of 6 years are not usually good candidates for cryosurgery with one exception and that is treatment of molluscum contagiosum which requires only a 3  seconds spot freeze which is relatively painless. Children between the ages of 6–12 years old can sometimes tolerate the discomfort of cryosurgery particularly when topical, local and/or regional anaesthesia is used. Liquid nitrogen can cause serious burns (frostbite) if not handled safely. Protective clothing, gloves and eyewear should be used when filling a cryogun or transporting liquid nitrogen. It should be stored in specially designed storage flasks (Dewers Flasks) and should never be placed in a sealed container without a vent as it is explosive if pressure is left to build up in a sealed container. It should not be stored in small rooms, cars or elevators as it can displace oxygen form the air if it leaks or spills which can lead to asphyxiation. There have been reports of deaths of laboratory technicians dying from asphyxiation as a result of leakage of liquid nitrogen in confined spaces. Liquid nitrogen should always be stored in a large well ventilated room and the room should be vacated immediately if there are any serious leaks or spills as liquid nitrogen is odourless and colourless [5].

58.4 Freeze-Thaw Cycle Maximum cell destruction is achieved by a rapid freeze followed by a slow thaw. The length of time it takes to freeze a lesion will vary depending on the size of the aperture or the probe on the cryogun and the size of the lesion being treated. A 20 seconds freeze with a small D spray tip on an actinic keratosis greater than 10 mm in diameter will be inadequate. On the other hand, a 20 seconds freeze with an A or B spray tip on a small actinic keratosis, less than 5  mm, may be too much. Most lesions up to 10 mm in diameter can be frozen with a C spray tip (Brymill Corp.©). It is important to define what “a freeze time” and “a freeze thaw cycle” really means, so that results can be compared, adequacy of treatment assessed and cryosurgery techniques can be properly taught to both doctors and nurses.

The following definition has been proposed when using liquid nitrogen via a cryogun [6]: • Start freezing at a fast rate using an appropriate size spray tip or probe for the size of the lesion (C or E tip for a small lesion 3 mm margins for plantar warts and 4–5 mm margins for small non-melanoma skin cancers) • Continue to freeze (spraying intermittently to avoid excessive lateral spread of the ice front) for the desired length of time (“freeze time”) e.g. 10 seconds for warts or actinic keratosis, 15  seconds for plantar warts, 30  seconds for MMSC (Table 58.2) • Let the lesion thaw out completely without external warming. Table 58.2  The freeze-thaw cycle using the open spray technique Diagnosis Molluscum Actinic keratosis Seborrhoeic keratosis without paring Seborrhoeic keratosis post paring Common warts Periungual warts Plantar warts Bowen’s diseasec BCC/SCCc 3

30

2

>6

a Interval after the complete lesion is frozen and a margin of normal uninvolved skin is also frozen (not the total spray time).C spray tip is suitable for tumours up to 10 mm in diameter and a B spray tip should be used for larger tumours up to 20 mm b FTCS freeze-thaw cycle c Not all non melanoma skin cancers are suitable for cryosurgery

58  Cryosurgery in Primary Care

• If a second freeze-thaw cycle is required (e.g. for warts, plantar warts or NMSCs) it can be started using the exact same technique as described above once the complete thaw has occurred from the first freeze. A second ­freezing will always be faster because there will be ice crystals in the tissue. Bulky lesions should be pared down or debulked prior to cryosurgery. Different techniques may be required for treating larger lesions (greater than 2 cm), when spraying down an otoscope cone, using a cryochamber or freezing in conjunction with imiquimod (i.e. immunocryosurgery). Sometimes, temperature monitoring at the base and periphery of a tumour may be more appropriate than measuring time when treating non-melanoma skin cancers.

539

58.6 Side Effects Serious side effects with cryosurgery are rare. Different tissues have different sensitivities to cryosurgery (Table  58.3). Melanocytes, for instance, are most sensitive to cold; this is why hypo or hyper-pigmentation post-cryosurgery can happen although this is temporary in most cases. As fibroblasts and collagen are less sensitive to cold, little or no scarring post-cryosurgery occurs. The periungal skin and cuticle are very sensitive to cold and permanent scarring can occur if this area is frozen too hard (Fig. 58.2). Pain, swelling and serious or haemorrhaging blistering can occur post-cryosurgery and patients should be warned about these side effects and instructed on how to manage them (Fig. 58.3). It Table 58.3  Sensitivity of tissues to cryosurgery

58.5 Immunocryosurgery Combining imiquimod 5% “(Aldara®)” with cryosurgery can enhance the success of both techniques compared to when they are used individually (immunocryosurgery). This combination can be used for genital warts, non genital warts (see Chap. 59) and selected cases of non melanoma skin cancers (NMSCs). For NMSCs, have the patient pre-treat the tumour daily for 8 hours for 2 weeks with imiquimod 5% cream. Then freeze the tumour, including a 4 mm border of surrounding uninvolved skin, for 15–20  seconds and with a double freeze-thaw cycle. Have the patient continue with imiquimod 5% topically immediately after the session of cryosurgery for another 3 weeks starting on the same day as the freezing. This cycle can be repeated if necessary [7]. Warn the patient that local side effects such as pain, swelling, crusting and inflammation can be unpredictable and sometimes severe. There may even be systemic symptoms such as a flu like illness during the treatment with imiquimod (see Chap. 45).

Sensitivity of Tissues to Cryosurgery. Melanocytes Basal Cell layer Keratinocytes Endothelial cells Venules Arterioles Nerves Fibroblasts Collagen

Most sensitive to cold

Least sensitive to cold

Fig. 58.2  Nail damage from previous cryosurgery for periungal warts

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Perfect techniques on carefully selected patients with good follow up and record keeping should ensure doctors do not freeze now and fry later in the hands of the lawyers!

References

Fig. 58.3  Haemorrhagic blisters 2 days post cryosurgery for warts

is probably better to delay cryosurgery if the patient has any major social or work engagements coming up in the following 2 week as weeping and blistering can be unsightly and uncomfortable. There have been rare reports about tendon rupture with cryosurgery but with proper techniques, this can almost always be avoided [8]. Temporary anaesthesia post cryosurgery over a nerve is not uncommon and the sensation usually returns after 3–6 months as the nerve regenerates.

58.7 Conclusion Techniques in cutaneous cryosurgery are best learned by seeing patients being treated by an experienced cryosurgeon. Articles in scientific journals, books, internet videos and CD’s are also available [9, 10]. All doctors and nurses should have adequate training prior to carrying out cryosurgery in their own surgery to ensure high success rate and a low incidence of side effects.

1. Holt PJ.  Cryotherapy for skin cancer: results over a 5-year period using liquid nitrogen spray cryosurgery. Br J Dermatol. 1988;119(2):231–40. 2. Nordin P.  Curettage-cryosurgery for non-melanoma skin cancer of the external ear: excellent 5-year results. Br J Dermatol. 1999;140(2):291–3. 3. Buckley D, Marczuk C, Kennedy T.  Cryosurgery for basal cell carcinoma treated in primary care. Ir J Med Sci. 2020; https://doi.org/10.1007/ s11845-020-02188-5. 4. Buckley D. Cryosurgery for non-melanoma skin cancer. In: Xu K, Korpan NN, Niu L, editors. Modern cryosurgery for cancer. Singapore: World Scientific; 2012. p. 865–92. 5. Standard operating procedure—liquid nitrogen—storage, use & transportation guidance & code of practice. University of Edinburgh School of Chemestry. http://www.chem.ed.ac.uk/sites/default/files/safety/ documents/cryogenic.pdf 6. Buckley D. Re: the freeze–thaw cycle in cryosurgery. J Eur Acad Dermatol Venereol. 2017;31:e405–6. https://doi.org/10.1111/jdv.14215. 7. Gaitanis G, Bassukas ID.  Immunocryosurgery for nonmelanoma skin cancer. Applications and practical tips. In: Pasquali P, editor. Cryosurgery. A practical manual. Cham: Springer; 2015. p. 245–58. 8. Yates VM, Scott MM, Carter ED. Rupture of tendon after cryotherapy for hand wart. BMJ. 297(6656):1106. https://europepmc.org/backend/ptpmcrender.fcgi?acc id=PMC1834863&blobtype=pdf. 9. Andrews MD. Cryosurgery for common skin conditions. Am Fam Physician. 2004;69(10):2365–72. 10. Pasquali P, editor. Cryosurgery. A practical manual. 1st ed. Cham: Springer; 2015. isbn:978-3-662-43938-8.

Cryosurgery for Warts in General Practice

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David Buckley

Key Points • For warts that require treatment, the first line of treatment is usually with topical creams, gels or solutions which the patient can use at home. • Cryosurgery is safe and successful when treating warts but the technique has to be perfect to get high cure rates. • Never freeze any lesion unless you are certain of the diagnosis. • Cryosurgery is painful and most warts >5 mm or cluster of warts are best treated under local anaesthetic using a 30 G needle. • Avoid using cryosurgery for warts in children under the age of 12 years and almost never in children under 6 years old. What to Tell the Patient • Most warts do not require treatment as many will clear spontaneously in time especially in children. • Cryosurgery for treating warts is highly successful but can be painful and may require local anaesthesia. • There may be some pain, swelling and sometimes blistering post cryosurgery and healing may take 2–3 weeks.

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland

• If you have cryosurgery for plantar warts you may be limping for a few days or weeks post-treatment.

59.1 Introduction Cryosurgery is a method of selectively destroying unwanted tissue using cold liquids or gasses. The aim is to cause maximum tissue destruction in the target lesion with minimal collateral damage to the surrounding healthy structures. Cryosurgery does not kill the human papilloma virus (HPV); in fact, viruses can survive and be preserved in liquid nitrogen. What we are trying to achieve with cryosurgery is to destroy the cells that are infected with the HPV by creating intracellular ice crystal formation that ruptures the cell, thus allowing clean, healthy, uninfected cells to take their place. Cryosurgery causes local swelling which blocks the small feeding vessels resulting in ischaemic necrosis of the frozen area, further enhancing cell death. Furthermore, it has the unique action of cryoimmunostimulation, whereby some of the wart virus is released from the frozen tissue after cryosurgery, presenting wart antigen to the immune system [1]. This acts like a vaccine, helping the body to fight off the HPV in the treated and sometimes even distant untreated warts (Fig. 59.1a, b). Patients who have a suppressed immune system are less likely to benefit from cryoimmunestimulation. Combining

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a

b

Fig. 59.1 (a) Plantar wart in a 13 year old (b) Same patient 1 month later with spontaneous resolution of the plantar wart on her 5th toe after treating a larger one elsewhere on her foot 1 month earlier

a

b

Fig. 59.2 (a) Recalcitrant hand warts in a 22 year old immunosuppressed woman. (b) Same patient cleared with cryosurgery and imiquimod 5%

imiquimod (“Aldara®”) with cryosurgery may enhance this response and this is known as immunocryosurgery [2] (Fig. 59.2a, b). There is only one important rule in cryosurgery: never freeze any lesion unless you are 100% sure of the diagnosis. If you cannot make a confident named clinical diagnosis, do not freeze—take a biopsy or refer the patient for another opinion. Success in cryosurgery is dependent on four main factors (Table 59.1): • • • •

Cryogen Delivery system Patient selection Technique

59.2 Cryogen Maximum cell destruction is achieved by applying temperatures of less than 40 degrees Celsius (–40 °C) at the base of the lesion (rapid freezing, due to temperature difference with human skin), followed by a slow thawing and carrying out at least two freeze-thaw cycles [3] (Fig. 59.3). This is best achieved by using cryogens with a very low boiling point such as liquid nitrogen (−196 °C), which is one of the coldest most versatile and cheapest cryogen available (Tables 59.2, 59.3, 59.4 and Fig. 59.4). Over the counter cryogens such as home freezers like “Wartner®”, which contain a mixture of dimethyl ether and propane (DMEP), are much less effective, as

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most only get down to −29  °C and have very poor penetration of tissues (see Fig. 59.5). Hand held medical devices such as the “Histofreezer®” or the “Dermafreeze®” also contain DMEP and are only suitable for very small, superficial lesions as the cryogen does not penetrate deeply. “Hydrozid®”, which is an aerosol can that contains a hydrofluorocarbon (norflurane), can reach Table 59.1  Success in cryosurgery is dependent on a number of factors

Success of Cryosurgery - Delivery of a lethal temperature - Duration of freeze - Rate of freeze - Rate of thawing - Number of freeze thaw cycles - Temperature at the base of the lesion

100 80 Cells killed %

Fig. 59.3 Percentage of cells killed with various freezing and thawing rates and temperatures. (courtesy of Mr Omar Maiwand)

temperatures of −60 °C at the surface but will not penetrate deeply (Fig. 59.6). It has a long shelf life and is portable. It is a reasonable alternative for those who do not have access to liquid nitrogen but it is not cold enough to treat deep or bulky tumours or skin cancers. Nitrous oxide gas, while not as cold as liquid nitrogen, can reach −89 °C and can give reasonably good results provided there is meticulous attention to technique (Figs. 59.4 and 59.7). Large devices with a handle and various contact probes and tips which are linked to a large tank of nitrous oxide are now much less popular as they are expensive to run and are bulky to store. The “Freeezepen®” and the “Dermapen Cryo®” are small hand held units with disposable capsules filled with nitrous oxide gas and have a long shelf life (Fig. 59.8). However, they are relatively expensive and have very poor penetration of the tissues. They are only effective for small, superficial lesions. Their advantage is the small size of the unit and the use of capsuled

60 40

Freeze

20 0

-15 to -25

-25 to -35

-35 to -50

Temperature/ Celsius

Table 59.2  Boiling point of the most common cryogens Ice (water) Ice (Saturate salt and water mix) Dimethyl ether and propane in a cotton bud (“Histofreezer®”) Norflurane (HFC) (“Hydrozid®”) Nitrous oxide Liquid nitrogen

−0°C −21°C −29°C −60°C −89°C −196°C

Thaw

Rapid Hold Slow Rapid Hold Rapid Slow Slow Rapid Slow Rapid Rapid Slow Rapid

D. Buckley

544

59.3 Equipment

nitrous oxide gas as a cryogen which has a long shelf life. These hand held nitrous oxide devices also avoid having to buy, store and refill a dewar flask with liquid nitrogen (Table 59.4).

Liquid nitrogen cryosurgery via a closed handheld cryogun is the safest, most effective and most versatile method to deliver a freeze (Fig. 59.9). Applying liquid nitrogen with a cotton bud is not as effective as a liquid nitrogen cryogen but is still more effective than nitrous oxide gas, “Hidrozid®”, “Histofreezer®” or the “Dermafreeze®”.

Table 59.3  There are four main cryogens used in clinical practice

Which Cryogen? Main cryogens: Dimethyl ether, propane+ isobutene (DMEP) (“Histofreezer®”, home freezing kits =“Wartner”)

59.4 Patient Selection

Hydrofluorocarbon (HFC) (e.g. Norflurane) (“ Hydrozid®”)

Patient selection is crucial in delivering effective cryosurgery. Children under the age of six do not make good candidates for cryosurgery for warts and doctors should resist parental pressure to freeze warts in this age group. The only excep-

Nitrousoxide (N2O). (“Welch Allen”,“Freesepen”,”Dermpen”, ”Cryo-omega”, “CryoSuccess”) Liquid nitrogen (LN) Cryogun

Table 59.4  Advantages and disadvantages of various cryogens DMEP (“Histofreezer®”) +

Safety Portability Shelf life Pain score (out of 10) Cure rate Cost per RX Various tips

N20 Handheld (“Freeze Pen®”) Explosive

N20 Tank (“Welch Allyn®”) Explosive

Liquid nitrogen Cryogun O2↓ Burns

+++ +++ 1/10

HFC (“Hydrozid®”) Global warming +++ +++ 3/10

+++ ++ 5/10

+ +++ 5/10

++ + 8/10

− Expensive −

+ Expensive −

++ Expensive +

++ Cheap ++

+++ Very cheap +++

0

–50

Min Temp on probe p

–29

Temp (˚C)

–60 –100

ice Histofreezer –100 Hydrozid

–150

Nitrous Oxide Liquid Nitrogen

–200

–200

–250

Fig. 59.4  Minimum tempature reached when the cryogen was places on the tip of the thermocouple (©David Buckley)

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tion is freezing molluscum contagiosum, which usually clear up with a tiny, almost painless, 3 seconds freeze. Children between the ages of 6 and 12 years old are generally poor candidates for cryosurgery unless the child (and not the parent) is highly motivated, can understand what is involved and is very eager for treatment. Avoid treating children with cryosurgery for warts greater than 4 or 5 mm in diameter or a cluster of warts together, unless the child can tolerate local anaesthetic. Other poor candidates for cryosurgery are needle phobics and immunosuppressed patients (daibetes, transplant patients).

large warts can be 4 or 5 mm deep. Success with cryosurgery is increased dramatically when a wart is de-bulked (Fig. 59.12a, b, c). Generally, this can only be achieved by applying local anaesthetic and surgically paring down the wart. Bleeding can be controlled with 20% aluminium chloride applied with a cotton bud, pressure and elevation. For most warts greater than 4 mm in diameter, or for a cluster of warts together, the discomfort of a prick with a 30 G needle with local anaesthetic is generally a lot less painful than trying to treat warts with cryosurgery without local anaes-

59.5 Technique There is a limit to the depth of freeze one can achieve with cryosurgery. As you freeze from the surface down, the isotherms get progressively warmer until equilibrium is reached between the cold of the cryogen at the surface and the heat of the skin from the underlying circulation (Figs. 59.10 and 59.11). Hypertrophic warts are often covered with thick keratin, which acts as a thermal insulator. This has to be removed with a blade to allow the freeze to penetrate to the base of the wart. Even after removing keratin, many Fig. 59.5 Isotherms created at different distances radiating from the heal sink source

Fig. 59.6 “Hydrozid®” (norflurane) can reach −60 °C.

Liquid N2 cryogen heat sink

A B2

B2

C2 B C in vivo skin Temperature of ice front: A = -120ºC; B = -50ºC; C = -25ºC Temperature of ice zones: B2 = -30ºC; C2 = -5ºC

C2

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546 Fig. 59.7  Nitrous oxide cryosurgery kit and tank

1

2

3

4 5 7 6 No.

Description

No.

Description

1

20# Cylinder

5

Cleaning Plugs and “0” Rings

2

20# Mobile Cart

6

Console

3

Carrying Case

7

Cyrogun

4

Quick Connect

Fig. 59.9 Liquid attachments

nitrogen

cryogun

and

various

thetic. A recent study by this author showed that the average pain score of cryosurgery without local anaesthetic was more than twice the pain score of administering the local anaesthetic with a 30-gauge needle [4] (Fig.  59.13). See Table 56.2 in Chap 56) on local anaesthetics for some techniques for minimizing the pain when giving local anaesthetic. For hand warts, have them flush with the surrounding skin by pearing them down with a scalpel blade before beginning cryosurgery and for plantar warts, scoop them out with a number 10

Fig. 59.8  Nitrous oxide handheld cryosurgery device

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547

Probe 2mm deep

20 15 10

Temp (C)

5 ice

0 -5

0

10

20

30

40

50

60

70

80

90

100

110

120

Histofreezer Nitrous Oxide

-10

Hidrozid

-15

Liquid nitrogen

-20 -25 -30

Time (seconds)

Fig. 59.10  Temperature reached with various cryogens with termocouple 2 mm deep in an ultrasound jel pad

Liquid nitrogen applied using different techniques with the thermocouple 2mm deep 20

10

0 0

10

20

30

40

50

60

70

90

100 110 120 6mm miniprobe

-10 Temp (°C)

80

Cotton bud -20

E Spray tip Auroscope Cone

-30

10mm Cryochamber -40

-50

-60

Time (seconds)

Fig. 59.11  Temperature reached with various probes and tips using liquid nitrogen with termocouple 2 mm deep

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548

a

b

c

Fig. 59.12 (a) Hand wart in a 18 year old (b) Hand wart post debulking under local anaesthetic (c) Same wart immediately post-cryosurgery with a C spray tip on a

Pain score (0-10). 0= no pain. 10 = worst pain ever. (20 patients). 10 With LA=2.1

8 P A I N

Without LA=5.4

6 4 2 0 1

FIg. 59.13  The difference between the pain of cryosurgery with and without local anaesthetic (ref. [3])

scalpel blade or a curette leaving a crater to freeze into (Fig. 59.14a–d). In this way, 75–90% of the wart is removed before starting the freeze. Another bonus is that the local anaesthetic makes the whole procedure far more tolerable for the patients and more enjoyable for the doctor.

hand-healed liquid nitrogen cryogun frozen for 10 seconds and 2 freeze-thaw cycles

Using this technique, success rate can be as high as 90% with one single treatment for hand warts and verrucas [4, 5] (Fig. 59.15a, b). Another advantage to de-bulking is that there is less necrotic tissue to die off post cryosurgery. The only disadvantage is that there can be a lot of bleeding during and after the treatment. Care should be taken not to contaminate the cryosurgical unit with blood. Put on a fresh glove just before picking it up for the freeze to avoid contaminating it with blood. Post-operative bleeding can be controlled by a pressure dressing and elevation. Heavy bleeding can usually be controlled with 20% aluminium chloride and/or alginate dressings combined with pressure dressing and elevation. In addition, a post-treatment bullae filled with blood or serous fluid is possible. Let the patient know about this possibility in advance. Post-operative pain can usually be controlled by giving paracetamol or ibuprofen immediately after the session of cryosurgery, before the local

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a

b

c

d

Fig. 59.14 (a) Plantar wart (b) Same patient post pearing under local anaesthetic (c) More pearing. (d) Immediately post cryo

aesthetic has had time to wear off. Most warts will heal in 3–6 weeks. Most bulky warts require two freeze-thaw cycles (Table  59.5). There is some controversy, even amongst expert cryosurgeons, as to what constitutes a freeze-thaw cycle. However, most now agree that the following definition is correct [6]:

59.6 W  hat is a 10 second FreezeThaw Cycle? • Start freezing at a fast pace using a B or C spray tip until the whole wart is frozen (Fig. 59.14d). • Continue freezing until a halo of clinically non affected skin, 1 or 2 mm, around the wart is also frozen. • Continue to freeze (at a slower rate by using intermittent bursts of liquid nitrogen spray to avoid excessive lateral spread) for 10 seconds. • Then let the wart thaw out completely without heating, before starting a second freeze thaw cycle exactly the same way, if required.

Freezing down the auroscope cone is a useful technique for plantar warts, which allows deeper penetration of the freeze, without too much lateral spread. This leads to a higher success rate with lower morbidity, such as blisters. Spray down the auroscope scope cone with a C or E spray tip for 10  second only, as this is a much more concentrated form of cryosurgery than using the open spray technique. Auroscope cones should be avoided on the dorsum of the hands and face as it can leave an unsightly round patch of hypo or hyper pigmentation. Flat warts (plain warts) are usually quite superficial and so are much easier to treat. They do not usually require paring or de-bulking because they are usually small and can often be treated without local anaesthetic. Ano-genital and mucous membrane warts are usually soft with no keratin and again do not usually require paring or de-bulking before cryosurgery. Topical anaesthetic (e.g. “Amitop®”) works well and quickly (~15 minutes) on mucous membranes. Periungual warts usually occur as a result of damage to the cuticle, which is normally self

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550 Fig. 59.15 (a) Hand warts before treatment with an open spray technique using liquid nitrogen via a hand held cryogun (b) Same patient a few months post cryosurgery

a

b

59.7 Immunocryosurgery

Table 59.5  Freeze-thaw cycles Type of wart Molloscum contagiosum Periungual warts Filiform wart Ano-genital warts Common wart Plantar wart Mosaic plantar wart

Freeze times (s) 3

Freeze-thaw cycles 1

7 10 3–10 10 10–15 15

1 1 1 2 2 2

inflicted from biting or picking (Fig. 59.16). They can be very difficult to manage, as the periungual skin is very delicate. A good technique is to pare them down and freeze them gently with a 5–7 seconds freeze and only one freeze thaw-cycle to avoid damaging the germinal matrix of the nail plate.

Imiquimod 5% (“Aldara®”) is a Toll-like r­eceptor (TLR) 7 agonist. that induces production of inflammatory cytokines including interferonalpha, tumour necrosis factor alpha, and interleukin-12, and also enhances antigen ­presentation to T-cells. The overall effect is an enhanced immune response to viral infection. It is licensed for genital warts but there are a number of studies using imiquimod for non-genital warts. Best results seem to be achieved when imiquimod is combined with cryosurgery. One technique is to pare down the thick keratin over the wart and apply imiquimod to the wart alternate days for 3 weeks. Cryosurgery (10  second freeze and one freeze thaw cycle) should be applied after the second

59  Cryosurgery for Warts in General Practice

551 Table 59.6  Side effects of cryosurgery

Side Effects of cryosurgery: Immediate: Pain Swelling Delayed: Blister formation (serous or haemorrhagic) Ulceration Secondary infection

Fig. 59.16  Periungual warts

week of imiquimod and imiquimod should then be continued immediately after the cryosurgical session daily for one more week. [7] (Fig. 59.2a, b). There is some, week evidence that oral zinc sulphate, 10  mg/kg/day for 2 months (max 600  mg/day) in divided doses with food may boost the immune system and help the body fight off the wart virus. It can be use it in conjunction with cryosurgery for resistant warts [8, 9].

Side Effects Prolonged: - Hypo or hyperpigmentation - Contracted scar - Hypertrophic scar - Skin atrophy - Paraesthesia - Hair follicle loss

59.8 Side Effects

59.9 Conclusion

Serous or haemorrhagic blisters may occure within a few days of cryosurgery Pigmented changes (hypo-pigmentation or hyper-pigmentation) can sometimes occur, particularly in dark skinned patients, but the pigment usually comes back after a few months, especially when the freeze thawcycle is not more than 10 seconds. Nerve damage is very rare when treating warts. If it does occur, for instance on the digital nerve, it may result in a temporary numbness of the side of the finger that will resolve after a few months (Table 59.6).

The maximum number of warts treated in any one session of cryosurgery should be limited to approximately six to ten. If a wart dose not cleared after three separate sessions of cryosurgery using perfect technique via a liquid nitrogen cryogun, there is little point in persisting with cryosurgery. It may be better to revert to other techniques or perhaps encourage the patient to simply live with the wart and keep it under control by paring it at home, which makes it look and feel better.

552

References

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5. Buckley D. Cryosurgery treatment of plantar warts in general practice. Ir Med J. 2000;93(5):140–3. 6. Buckley D.  Re: The freeze–thaw cycle in cryosur 1. Buckley D. Cryosurgery for warts. In: Pasquali P, edigery. J Eur Acad Dermatol Venereol. 2017;31:e405–6. tor. Cryosurgery. A practical manual. 1st ed. Cham: https://doi.org/10.1111/jdv.14215. Springer; 2015. p. 107–19. isbn:978-3-662-43938-8. 7. Gaitanis G, Bassukas ID.  Immunocryosurgery for 2. Gaitanis G, Nomikos K, Vava E, Alexopoulos EC, nonmelanoma skin cancer. Applications and practical Bassukas ID.  Immunocryosurgery for basal cell tips. In: Pasquali P, editor. Cryosurgery. A practical carcinoma: results of a pilot, prospective, open-­ manual. Cham: Springer; 2015. p. 245–58. label study of cryosurgery during continued imiqui 8. Al-Gurairi FT, Al-Waiz M, Sharquie KE.  Oral zinc mod application. J Eur Acad Dermatol Venereol. sulphate in the treatment of recalcitrant viral warts: 2009;23(12):1427–31. randomized placebo-controlled clinical trial. Br J 3. Baust JG, Gage AA, Robilottto AT, Baust JM.  The Dermatol. 2002;146:423–31. pathophysiology of thermoablation: optimizing cryo 9. Mun JH, Kim SH, Jung DS, Ko HC, Kim BS, ablation. Curr Opin Urol. 2009;19(2):127–32. Kwon KS, Kim MB.  Oral zinc sulfate treatment for 4. Buckley D.  Evaluation of local anaesthetic infiltraviral warts: an open-label study. J Dermatol. 2011 tion for cryosurgery of hand warts: a prospective Jun;38(6):541–5. comparative study. Ir J Med Sci. 2016;185(3):561–4. https://doi.org/10.1007/s11845-015-1301-x.

A Practice Nurse Led Cryosurgery Clinic

60

David Buckley

Key Points • Techniques in cryosurgery are relatively simple to learn. The real skill is knowing which patient to treat and with which method. • A named diagnosis should be confirmed clinically or histologically by a doctor experienced in lesion recognition before a nurse starts treating a lesion with cryosurgery. • Nurses should not treat any lesion unless they are absolutely sure of the diagnosis. • Adequate analgesia and debulking prior to cryosurgery are important in order to achieve a high cure rate and satisfied patients. • Children are not good candidates for cryosurgery.

60.1 Introduction Nurses have been carrying out cryosurgery in dermatology outpatients for many years. The biggest growth area in the use of cryosurgery in the past 20 years has been in primary care. Many practices now have excellent cryosurgical equipment. For those practices fortunate enough (or wise enough) to have a practice nurse, it may be more appropriate to delegate some of the cryosurgical work to the nurse. The technique of D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland

cryosurgery is relatively easy to learn and provided the nurse confines her treatment to certain areas, (e.g. warts, verrucae and molluscum contagiosum, in patients over the age of 12 years old), it is unlikely that there would be any serious complications to the treatment. The only really important safety rule in cryosurgery is that no lesion should be treated unless there is absolutely certainty of the diagnosis. For example, a warty lesion on the back of a hand of a 60 year old male may not be a viral wart. Skin cancers sometimes present like this. Corns and verruca can sometimes be difficult to distinguish even by experienced dermatologists. Great care should be taken when treating pigmented lesions as a suspected seborrhoeic keratosis may turn out to a malignant melanoma. It can sometimes be impossible to distinguish an actinic keratosis form a squamous cell carcinoma on clinical grounds alone. Therefore, it is probably safer that a named clinical diagnosis be confirmed by the doctor (and noted in the chart) prior to the nurse carrying out the cryosurgery (see Chap. 58).

60.2 Techniques Cryosurgery is a painful procedure. Always lie the patient down before cryosurgery, especially in younger patients, as fainting is relatively common. For larger warts or verrucae greater than 4  mm in diameter or for a cluster of warts

© Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_60

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together, it is much less painful to inject a small amount of local anesthetic under the wart using a 30 gauge needle rather than trying to treat the wart without a local anesthetic [1]. Local anesthetic will also allow paring down the wart or verrucae more deeply prior to cryosurgery and this should ensure higher success rates. Topical anesthetics (e.g. “EMLA®” or “AMITOP®”) have not been shown to significantly reduce the pain of cryosurgery for warts but they will ease the discomfort of a local anesthetic injection if applied 30–60 min beforehand. Tetracaine gel (“AMITOP Gel®”) alone may provide sufficient anesthesia for treating warts on mucus membranes (e.g. genital warts) and usually works within 10–15 min in these areas. Treating children under 6 years old with cryosurgery is usually difficult and unrewarding and other methods should be applied if at all possible. The one exception would be molluscum contagiosum. They respond extremely well to cryosurgery and require a very light freeze (2–3 seconds) since they are extremely cryosensitive. Children may tolerate this level of discomfort without an anesthetic if they are well motivated. However, most molluscum clear spontaneously within 6–12 months especially if the area is treated with a thick greasy ointment like emulsifying ointment and they do not usually require cryosurgery. Warn all patients about the possibility of pain, swelling, blistering and hypopigmentation. All patients should be given verbal and written instructions on how to manage post-operative blisters and pain (see Chap. 66). Most warts and verrucae can be frozen using the open spray technique after paring off the hard keratin. The nossel of the cryogun is held about 10 mm away from the skin. The lesion is frozen until it goes completely white. The freezing is continued until a halo of 1 or 2 mm of surrounding normal skin is also frozen. The freeze is then maintained at this level for 10 seconds by short rapid pulses of liquid nitrogen spray, being care-

ful not the let the ice ball extend more than 1–2 mm beyond the wart. The lesion is allowed to thaw out completely without external heating. If a second freeze-thaw cycle is required, the procedure is repeated immediately once the wart has thawed out after the first freeze. The technique of cryosurgery is best learnt from expert cryosurgeons and by practical demonstrations on patients (see Chap. 59). Some viral warts such as periungual warts and mosaic verrucae can be very difficult to treat and are probably best left to expert cryosurgeons. Larger warts (greater than 5  mm) may require local anesthetic and unless a practice nurse is capable of administering it, these warts are best left to the doctor in the practice who is most experienced in cryosurgery.

60.3 Conclusion Good record keeping is important. Written informed consent is recommended when freezing simple warts or verruca. Patients should be warned about the possibility of post-operative pain, bleeding, blistering and hypo or hyper pigmentation. The size, position and number of lesions and the exact type of treatment given should be recorded (record freeze times, number of freeze thaw cycles and type of tip used on the cryogun). A note should also be kept as to whether topical or local anesthetic was used and whether oral analgesics were administered. Good records will be of great help should there be any problems that might lead to a medico legal case. Detailed surgical notes of the procedure will also facilitate audit and research.

Reference 1. Buckley D. Evaluation of local anaesthetic infiltration for cryosurgery of hand warts: a prospective comparative study. Ir J Med Sci. 2016;185(3):561–4.

Part XIII Pharmacology and the Skin

61

Pharmacists and Skin Disease David Buckley

Key Points • Pharmacists can diagnose and treat many minor skin complaints using simple over the counter non prescription items. • Pharmacists can play a role in the primary care team working alongside doctors and nurses to help patients manage acute and chronic skin problems. • Pharmacists can advise patients on the correct method of applying medications such as creams and gels and warn them about possible side effects and what to look out for. • Pharmacist also monitor drug treatments for skin diseases checking for interactions with other medication and for drug allergies. What to Tell the Patient • For minor skin aliments such as sun burn, mild acne, mild eczema or athletes foot your pharmacist may be able to diagnose and treat your skin problem. • One of the key measures in skin cancer prevention is the careful use of high potency sun protection factors which your pharmacist should be able to advise you on. These are also one of the best anti-aging measures you can adopt.

61.1 Introduction Skin care products account for 17% of pharmacy over-the-counter (non-prescription) sales [1]. Symptomatic skin problems make up to 12–23% of all symptom based requests for advice from pharmacists. Pharmacies see a wide variety of skin complaints that can vary according to the seasons (Table  61.1). Simple advice from the community pharmacists can enhance the effectiveness of over-the-counter and prescription skin care products. The community pharmacist can also facilitate effective self care for patients with dermatology problems who wish to treat themselves. Patients often present to their pharmacist before their doctor with skin problems because of ease of access to the pharmacist and it may be less expensive. Table 61.1  Common ailments seen by the community pharmacist Spring/summer Insect bites and stings Sun burn Cuts and scrapes Cold sores (Herpes simplex) Warts, verrucas and corns Hives (urticaria) Thrush (candidiasis)

Autumn/winter Acne Eczema/dermatitis Dry skin Psoriasis Dandruff Head lice Athletes foot (Tinea pedis) Impetigo

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland © Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_61

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558

61.2 Diagnosis When a patient presents to the pharmacist with an undiagnosed skin condition, the pharmacist will have to assess the patient and decide whether to refer them on to their GP or treat them with simple over the counter products. As in general practice, the range of diagnostic skills in dermatology amongst pharmacists is very variable. Further training in dermatology for pharmacists could be beneficial.

61.3 Treatment of Skin Diseases The pharmacist’s ability to manage skin problems is limited as they cannot at present dispense certain common prescription topical and systemic treatments such as potent topical steroids or antibiotics without a doctor’s prescription. However, when treating common skin conditions such as eczema, over-the-counter products such as emollients, soap substitutes and the careful use of gloves are often as important, if not more important, than the use of prescription items such as potent topical steroids.

61.4 Health Promotion Health promotion and disease prevention is also an important part of the pharmacist’s role. In skin care, this primarily centres on advice regarding protection of the skin from excessive ultraviolet light to prevent skin aging and skin cancers. Sunblocks play an important role in this respect. Pharmacies should have a basic knowledge about the early signs of skin cancer especially melanomas. Patients who must avoid sun exposure completely such as those with photosensitivity or those who have previous skin cancer, will need advice on vitamin D supplementation.

61.5 Chronic Disease Management Pharmacists play an important role in chronic disease management of common skin illness such as acne, eczema and psoriasis. The first line treatment for many common skin diseases such

D. Buckley

as eczema and acne is simple over-the-counter topical treatments that can be initiated by the pharmacist. The pharmacist can reinforce the advice given by the GP, dermatologist or practice nurse about how to apply various topical treatments, how much to use, on which particular area of the body and how long it should take before improvements are seen. He/she should be able to discuss possible side effects of medication for dermatology problems such as those from potent topical steroids and be able to reassure the patient that when used correctly under careful medical supervision, side effects are very rare. Many topical acne treatments such as benzoyl peroxide and adapalene are potentially drying and irritating when first used. The pharmacist can advise the patients on how to apply these products sparingly initially all over the acne affected areas and not just onto spots. Pharmacist can also monitor drug treatments for skin diseases by looking for interactions with other medication and checking for drug allergies. In the UK, pharmacists are now included in primary care teams to enhance compliance and safety of treatments resulting in better outcomes. Pharmacists need to be more precise when advising on topical treatments. For instance, it is common practice for pharmacists is to write “use sparingly” when prescribing potent topical steroid. This is meaningless as “sparingly” can be interpreted differently by different patients. Doctors and pharmacists should be encouraged to advise the patient how much of a particular topical steroid they can safely use on certain parts of the body per month (e.g. adults can use 120 g of a potent topical steroid per month for extensive eczema on the body but not on the face). Another area of chronic disease management where the pharmacist can play a part is in the treatment and prevention of varicose eczema and varicose ulcers. Provided there is no evidence of peripheral vascular disease, pharmacists can measure and fit patients for high compression hosiery which can help heal small ulcers and prevent the recurrence of new varicose ulcers. Proper compression is more important than expensive wound dressings when managing varicose ulcers and varicose eczema. Hair and nail problems are also commonly seen by community pharmacists. They have a

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Table 61.2  Range of conditions and over-the-counter treatments available from the community pharmacist in Ireland Eczema/dermatitis/dry skin (see Chaps. 13, 14 and 62)

Acne (see Chap. 7)

Fungal infection (see Chap. 31)

Dandruff/Seborrhoeic Dermatitis/Pityriasis versicolour (see Chaps. 16 and 31) Hyperhidrosis (see Chap. 12) Psoriasis (see Chap. 15) Warts/Verrucas/Corns (see Chap. 34)

Cold sores (see Chap. 32) Scabies/Pubic and head lice (see Chap. 35)

Urticaria hives and allergic reactions (see Chap. 20) Hair loss (see Chap. 40) Varicose eczema Varicose ulcers (see Chap. 37) Skin cancer, photo protection and skin aging (see Chaps. 45 and 49)

– Emollients – Soap substitute and bath oils – 1% Hydrocortisone cream – Gloves – Wet wrap garments – Salicylic acid washes – Benzoyl Peroxide – Nicotinamide gel – Imidazole creams (e.g. “Canestan®”) – Allylamine creams (e.g. “Lamisil cream®”) – Amorolfine nail lacquer – Ketoconazole shampoo (“Nizoral®”) – Selenium Sulphide (“Selsun®”) (“Head & Shoulders®”) – Simple underarm deodorants – Aluminium Chloride (“Anhydrol Forte®” or “Driclor®”) – Coal tar e.g. “Exorex lotion®”, “Cocois ointment®”, Calcipotriol (“Dovonex®”) – Salicylic acid paints – Corn plasters – Files and blades – Acyclovir cream – Malathion – Permethrin – Dimethazone – Non-sedating antihistamines – Volumizing shampoos – Minoxidil (“Regaien®” or “Rogaine®”) – Compression stockings – Ulcer dressings – Sunblocks (SPF) – Vitamin D

wide range of over the counter products to help deal with these problems including dandruff, hair loss and fungal nail infections. Table 61.2 outlines the range of conditions and the treatments available for use by community pharmacists in Ireland.

best treatments available and to ensure they are used safely and effectively. The pharmacist can help the doctor source difficult to get or off-­licensed drugs at a competitive price for their patients.

61.6 Conclusion

1. Tucker R, Duffy J. The role of the community pharmacist in the management of skin problems. J Pharma Care Health Sys. 2014;1:1.

Pharmacists and doctors should work together as a team to provide the patient with skin disease the

Reference

Emollients and Moisturisers

62

David Buckley

Key Points –– Most dry skin conditions should benefit from a moisturiser. The best moisturiser is the greasiest one the patient will use. –– The primary aim in the management of eczema is to reverse the dryness and reduce the itch by the appropriate use of emollients and the avoidance of soaps, irritants and allergens which should help restore the skin barrier function. –– Eczema sufferers should use hypo-­allergic, oil based moisturisers that come in sufficiently large quantities and are relatively inexpensive, as they will have to be used in high quantities over a long period of time. –– Ointment based moisturisers are more effective but also more greasy to use. –– Sometimes giving the patients a few different moisturisers to use at different times of the day can help; for example a thick greasy moisturiser at night and a lighter less greasy moisturiser for work or school. –– Moisturising is steroid sparing.

62.1 What to Tell the Patient –– When using a greasy moisturiser, always rub it downwards as rubbing it up and down may cause irritation or infection to the hair folliD. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland

–– –– –– –– ––

cles. If applied in excess, wait a few minute and then rub down again. Sufficient moisturisers are necessary to cover the affected areas at least twice a day. Avoid moisturisers with perfumes, colourings and sulphates. Use approximately ten times more moisturiser than topical steroids with treating eczema. Keep away from fire or flames and do not smoke when using paraffin based moisturisers. Moisturisers are one of the best ways to relieve itch in dry skin conditions.

62.2 Introduction The drug of first choice for most dry skin conditions such as eczema, psoriasis, or ichthyosis is a safe greasy moisturiser. The basic underlying problem in most forms of eczema is dry, itchy skin that leads to a defective skin barrier function, making the patient susceptible to infection, irritants and allergens. Scratching further compromises the skin barrier function. The primary aim in the management of eczema is to reverse the dryness, reduce the itch by the appropriate use of emollients and the avoidance of soap, irritants and allergens which should help restore the skin barrier function. Topical steroids (TS) and topical immunomodulators (TIM) such as tacrolimus, may ease itch and inflammation but they will do nothing for dry skin.

© Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_62

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A recent Cochrane review showed that moisturisers showed some beneficial effects; prolonging time to flare, reducing the number of flares and the amount of topical corticosteroids needed to achieve similar reductions in eczema severity. Moisturisers combined with active treatment gave better results than active treatment alone. They did not find reliable evidence that one moisturiser is better than another [1]. It is important to show and demonstrate to the patient how to apply greasy moisturisers. They should be rubbed downwards like stroking a cat, especially on the hairy areas of the body, as rubbing up and down will irritate the skin and may cause folliculitis. It is useful to keep a wide range of various emollients and soap substitutes in the doctor’s office to show the patients or parents what they look like, their consistency and to give them some idea how long a tub or tube should last (Fig. 62.1). If the patient wants to sample an emollient in a tub, remove some with a tongue depressor to give to the patient so as to avoid contaminating the tub with fingers. The best moisturiser is the greasiest one the patient will use. They should be hypo-allergic and fragrance, preservative and SLS free. Cosmetic type moisturisers are unsuitable for eczema sufferers as they are usually too light, the quantities too small and they tend to be too expensive. In addition, they often contain many colourings, preservative and perfumes which the eczema sufferer should avoid. Eczema sufferers should only use hypo-allergic, oil based moisturisers that come in sufficiently large quantities and are relatively inexpensive, as they will have to be used in high quantities over a long period of time.

Fig. 62.1  Emolient tray

D. Buckley

62.3 Ointments Versus Creams Many years ago, the advice given to medical students was if a rash is wet (weepy), you should dry it with creams and if is dry you should wet it with ointments. Although there is still some truth in this, there are now a very wide range of topical formulations available for various situations (Table 62.1). Emulsifying ointment is cheap, safe, effective water-in-oil emollient ointment. Because it is so greasy it only has to be applied twice a day, unlike some moisturising creams which may have to be applied every few hours. However, a lot of patients will not use emulsifying ointment as they find it too thick and greasy and it may sting the skin as it contains sodium lauaryl sulfate (SLS) which is a surfactant used in many cleaning products and detergents. It is important to give the patient a choice of different moisturisers—a greasy water-in-oil one such as “Paraffin Gel ”, “Epiderm ointment®”, “Hydromol ointment®” or “Diprobase ointment®” (Table  62.2) and a less greasy oil-inwater emollient cream such as “Aveno Dermexa®”, “Epiderm Cream®” or “Oilatum Cream®” (Table 62.3). It is kinder and more realistic to get the patient to use the greasier but more effective moisturiser at home at night and to use the less greasy but cosmetically more acceptable moisturising cream during the day, especially if is needed on their face or hands at work or at school. “Doublebase Emollient Gel®” is half way between an ointment and a cream. It is highly moisturising yet cosmetically acceptable. It contains liquid paraffin, isopropyl myrisate and glycerol which is a humectants which helps retain moisture in the skin (Table 62.4). Sufficient quantities of moisturisers need to be given (Table 62.5). Adults with dry skin all over may need 1000 g/month if they are to apply their moisturiser all over twice a day. Children may need approximately half this amount. Emollients are steroid sparing. As a general rule of thumb, the patient needs ten times more moisturiser that topical steroid or TIM such as tacrolimus. So, if prescribing 100 g of a potent topical steroid every

62  Emollients and Moisturisers

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Table 62.1 Topical formulations

Powder Lotion

Paste

Liquid (Water or alcohol)

Fat (Oil)

Gel

Ointment

Cream Cream: - Oil in water (mostly water) (e.g. Aqueous cream*) - Light and creams - Cosmetically acceptable - Contain preservatives which may cause allergies *Aqueous cream contains Sodium Lauryl Sulfate (SLS) which is a surfactant and detergent which should not be used in sensitive skin such as atopic eczema Ointment: - Water in oil (mostly oil) e.g. emulsifying ointment - Thick and greasy – useful for dry skin - Can be messy and sticky - Occlusive effects enhances skin barrier function - No preservatives - Not suitable for hairy areas - May cause folliculitis (‘’rub downwards’’) Paste: - Powder and ointment (e.g. zinc oxide paste or Lassar’s paste) - Does not spread - More sticky and more difficult to rub off Lotion: - Liquid preparation – usually has to be shaken to mix the content (e.g. “Betnovate Scalp Application®”, “Calamine lotion®”) - The solvent evaporates to leave the active ingredient in contact with the skin and a cooling sensation - Not sticky and dry fast (e.g. acne lotions) - Suitable for hairy areas and acne prone skin Gel: - A water-alcohol mix (e.g. “Dovobet gel®”) - Liquefy on contact with the skin leaving a thin film of active medication - Drying, cosmetically acceptable - Useful on hairy areas and acne prone skin

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564 Table 62.2  Common emollient ointments (water-in-oil) Emulsifying ointment 500 g (contains SLS) “Hydrous ointment®” 500 g “Diprobase ointment®” 500 g “Paraffin gel®” (50; 50 liquid paraffin/white soft paraffin) 500 g “Hydromol ointment®” 500 g “Epiderm ointment®” 500 g Table 62.3  Common Emmolient creams (oil-in-water) “E45®” 500 g (contains lanolin) “Oilatum cream®” 500 g “Epiderm cream®” 500 ml “Diprobase cream®” 500 g “Aveno Daly Moisturising Lotion®” 200 ml + 354 ml “Aveno Dermexa cream®” 200 ml Table 62.4  Emollient Gels “Doublebase emollient Gel®” 100 g/500 g Table 62.5  Amount of cream or ointment required to treat a skin condition twice daily for a month Age 6 months 1 year 4 years 8 years 12 years 16 years Adulta

Whole body 144 g 184 g 240 g 320 g 480 g 624 g 680 g

Both arms and legs 80 g 104 g 144 g 200 g 264 g 344 g 360 g

Trunk 64 g 64 g 80 g 144 g 184 g 224 g 240 g

Adapted from Maurice PDL, Saihan EM. Br J Clin Pract 1985; 39: 441–2 a 70  kg male (All other figures given are a means of the values for male and female subjects)

month, 1000  g of moisturiser should be prescribed monthly.

62.4 Active Ingredients Urea based moisturisers (e.g. “Calmurid®” “Eucerin®” or “Relife U=Life”®) are less greasy but can sting if applied to broken skin. They act as a humectant which works by attracting water from the dermis below and helping to keep that water bound in the stratum corneum. 10%–30% urea based emollients can be useful in ichthyosis

and keratosis pilaris. It is also a good foot moisturiser. 3% urea is more suitable for the face and for children. Urea should be avoided in children under the age of 3 years old. Glycerol which is in “Doublebase Emollient Gel®” also acts as a humectant. Glycyrrhetinic acid (in Bioderma “Sensibo Rich Cream®”) is a major metabolite of glycyrrhizin, one of the main constituents of licorice. Both glycyrrhetinic acid and glycyrrhizin have been shown to exhibit anti-inflammatory, and immunomodulatory properties. The active ingredients in all “Aveeno®” products are colloidal oats and/or oat extracts— avenanthramides, which have the most anti-irritant properties of all oat extracts. The “Aveeno Dermexa®” range is enriched with avenanthramides to help soothe and relieve itchy, dry skin conditions such as eczema. “Aveeno Dermexa®” is a good cooling cream, especially if it is stored in the fridge, and can be helpful with rosacea, flushing or sunburn. “E45®” is a cheap moisturising cream but it contains lanolin (wool alcohol) to which some people may be allergic, especially if they have atopic eczema. “Oilatum cream®” contains light Liquid Paraffin and White Soft Paraffin which exert an emollient effect by forming an occlusive film which reduces trans-epidermal water loss, thus helping to maintain normal skin humidity levels. Oilatum cream also contains polyvinyl pyrrolidone which enhances the strength and longevity of the occlusive film on the skin. Greasy moisturisers should be avoided in acne prone skin. Oil free, non comodogenic moisturising creams should be used in these areas, if required, because of the overuse of anti-acne topical therapies or from oral isotretinoin. Most patients with acne have oily skin and do not need moisturising. Paraffin based moisturisers are flammable. The risk is greater when these preparations are applied to large areas of the body and clothing or dressings become soaked with the emollient. Patients should be told to keep away from fire or flames and not to smoke when using these preparations.

62  Emollients and Moisturisers

Zinc and castor oil is a good lubricant and acts as a barrier cream. It is most commonly used for babies bottoms to treat and prevent nappy rash. It is also useful in adults who have problems with skin friction and irritation such as pruritus ani, pruritus vulva, or intertrigo. Tar based products such as 10% coal tar, 10% tar and 10% urea, or “Exorex Lotion®” (5% coal tar solution) can be helpful for dry skin conditions especially psoriasis and it offers some mild anti inflammatory effects. Topical salicylic acid is sometimes added to a moisturiser or tar (e.g.“Cocois®”) as it acts as a keratolytic agent, de-scaling thick, scaly skin conditions such as scalp psoriasis. Non-paraffin based moisturisers such as coconut oil, bees wax or olive oil may suit some patients who are intolerant to paraffin based products which are made from crude coal tar. It may be helpful to give the patient a small amount of two or three different types of moisturisers to try out to see which one suit them best and which is most cosmetically acceptable for them. They could rub one sample downwards on one arm and another on the opposite arm for a few days. It should soon become apparent which one is most effective and acceptable. Wet wraps are another way of locking moisturisers into the skin and can prevent skin damage created by scratching. Wet wrap garments (tight cotton tops and pull ups) are more popular and more practical that tubular dressings that were used in the past. A damp garment is put on after moisturising the skin and this is covered with a second dry garment. These can be left on overnight or 24 hours and usually ease itch considerably in children with severe atopic eczema. Topical steroids may be put on the badly affected areas under the wet garments. Some light moisturisers come in pump dispensers which are handy for measuring out a fixed amount and stops dirty fingers going into the pot contaminating the contents. Thick, greasy moisturisers will not work in a pump dispenser. When taking ointments out of the pot please instruct the patient or parent to use a spoon so as to avoid contaminating the pot.

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62.5 Soap Substitutes and Bath Oils It is very important to encourage the patient with dry skin to avoid soaps and other irritants such as shampoo, shower gels, bubble baths, detergent and washing up liquids. All of these agents will break down what little natural oils the eczema sufferer will have left in their skin and they will make their eczema worse. Safe alternatives such as “Elave Wash®” and “Elave Shampoo®” or “Aveno Wash®” should be encouraged. People whose job involves getting their hands wet a lot such as homemakers, hairdressers, kitchen workers, plasterers and dairy farmers should wear gloves for all wet work, not only when their hand rash is troublesome, but also as they improve to prevent relapse. They should also use safe soap substitutes and use a soap free shampoo or else wear surgical gloves when washing the hair using their ordinary shampoo. Emulsifying ointment and “Epiderm Ointment®” can also be used as soap substitutes but they are not as comfortable to use as the proprietary soap substitutes such as “Elave Wash®” or “Aveno Body Wash®”. “Dove soap®” and “Simple soap®” should be avoided in patients with dry skin. “Aqueous Cream BP” and “Silcocks Base BP” can be used as a soap substitute. Despite claims from the manufacturers, these should not be used as a moisturiser as they may contain sodium lauryl sulfate (SLS) which is a surfactant used in many cleaning products and detergents. Leaving “Aqueous cream BP” or “Silcock’s Base BP” on the skin is akin to leaving shampoo on the skin which is obviously not a good idea for eczema sufferers. Bath oils may help to get moisturisers into the skin, especially in children, although recent evidence for their effectiveness is poor [2]. Emulsifying ointment or “Epiderm Ointment®” can be dissolved in a small amount of boiling water and added to the bath but they usually float as globules on the top of the bath water. It is much better to use special bath oils such as “Oilatum®” or “Aveno Bath Emollients®” which will dissolve easily in the bath water and soak into the skin. Great care should be taken as bath oils make the bath very slippery. Bath mats should be

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encouraged to avoid falls and baths should be limited to 5–10 min. After getting out of the bath the skin should be patted dry with a soft cotton towel and immediately covered in a greasy moisturiser to “lock in” the bath oils. For infective exacerbations of eczema “Oilatum Plus Bath Emollient®” (or “Oilatum Junior Flare Up®” for children) can be used daily for a week as they contains antiseptics which help clear infections. An alternative for recurrent skin infection is “Milton® baths” twice a week but this may have to be combined with a bath emollient (see patient info leaflet on Milton baths in Chap. 66). However, there are very few good clinical studies published in the literature on the use of bleach baths for the adjunctive treatment of patients with infected atopic eczema [3]. Potassium permanganate soaks are also good for skin infection.

62.6 Conclusion When treating dry skin conditions, it is often more important to advise the frequent use of an appropriate moisturised (Table  62.5) and soap substitute than prescribing topical steroids.

The management of dry skin requires a lot of hard work by the patient since they will constantly have to moisturise their skin and change most of their toiletries and cosmetics not just when their skin is irritated, but for the long term. Patients or parents should be given written information on the choices of emollients, bath oils and soap substitutes available over the counter in the pharmacy and how to use these products. (See Chap. 66 PIL. “Management of dry sensitive skin conditions”).

References 1. van Zuuren EJ, Fedorowicz Z, Christensen R, Lavrijsen A, Arents BWM.  Emollients and moisturisers for eczema. Cochrane Database Syst Rev. 2017;2(2):CD012119. https://doi. org/10.1002/14651858.CD012119.pub2. 2. Santer M, et  al. Emollient bath additives for the treatment of childhood eczema (BATHE): multicentre pragmatic parallel group randomised controlled trial of clinical and cost effectiveness. BMJ. 2018;361:k1332. 3. Barnes TM, Greive KA.  Use of bleach baths for the treatment of infected atopic eczema. Australas J Dermatol. 2013;54(4):251–8. https://doi.org/10.1111/ ajd.12015.

Steroids in Dermatology

63

David Buckley

Key Points –– Used properly and appropriately, under careful medical supervision, topical steroids (TS) are very safe and effective. –– Underuse of topical steroids is now a more common problem than overuse and abuse. –– Compliance with treatment will be improved if a frank and honest discussion is carried out with the patient about the risk and benefits of TS especially if the patient or parent is a steroid phobic. –– The safe use of topical steroids involves knowing how much and which potency of topical steroids to put on which part of the body and for how long. –– Ointments have a greater penetration than creams so TS that have an ointment base are considered more potent than the same TS in a cream base. –– Wrapping an area where TS has been applied with wet wraps or kitchen cling wrap will increase its potency, reduce chances of losing the cream on clothes or sheets and reduce scratching. However, it can increase the risk of skin thinning if continued too long.

D. Buckley (*) The Ashe Street Clinic, Tralee, Co. Kerry, Ireland

63.1 What to Tell the Patient –– When used under careful medical supervision, topical steroids (TS) are safe and effective for a wide range of inflammatory skin disease. –– As a general rule nothing stronger than a weekly potent TS (e.g. 1% hydrocortisone) should be used on the face in adults and children and nothing stronger that a moderately potent TS should be used on the body in children or potent TS on the body in adults. –– TS should always be reduced or stopped gradually if they have been used for more than a few weeks, as suddenly stopping them may result in a rebound flare of the underlying conditions (e.g. Psoriasis).

63.2 Introduction The introduction of topical steroids (TS) in the 1950s is still one of the greatest advances in dermatology as they provide substantial relief in a wide range of dermatoses in a safe, cosmetically acceptable form (Table  63.1). Overuse of very potent topical steroids in the 1970s caused local adverse effects such as skin atrophy, striae, telangectasia or systemic side effects such as hypothalamic–pituitary–adrenal axis (HPA axis) suppression and Cushing’s disease, and gave steroids a bad name generally (Fig. 63.1). Now most doctors understand that, used properly and appro-

© Springer Nature Switzerland AG 2021 D. Buckley, P. Pasquali (eds.), Textbook of Primary Care Dermatology, https://doi.org/10.1007/978-3-030-29101-3_63

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568 Table 63.1  Steroid responsive dermatoses Eczema/dermatitis Atopic eczema Contact dermatitis Pompholyx Seborrhoeic dermatitis Varicose eczema Discoid (nummular) eczema Neurodermatitis (lichen simplex chronicus) Papulo squamous Lichen planus Psoriasis Autoimmune Lupus (DLE,SLE) Alopecia areata Morphoea Vesicular/bullous Dermatitis herpitiformis Bullous pemphigoid Pemphigoid vulgaris Miscellaneous: Keloids + hypertrophic scars Papular urticaria Lichen sclerosis Pruritus ani Pruritus vulva Pyoderma gangrenosum Polymorphic eruption in pregnancy

priately, under careful medical supervision, topical steroids are very safe and effective. However, the general public still needs a lot of reassurance and education about their benefits. In one recent Italian study, 81% of parents of children with atopic eczema reported to have a certain amount of fear of TS [1]. Underuse of topical steroids is now a more common problem than overuse and abuse. TS have anti inflammatory and immunosuppressive effects. They also have anti-mitotic effects which can cause steroid atrophy. In addition they have a vasoconstriction effect which is sometimes used as a grading scale to judge their potency. They can also cause skin whitening: this is the reason why they are included in cosmetic products used to reduce hyperpigmentation. The safe use of topical steroids involves knowing how much and which potency of topical ste-

Fig. 63.1  Echymosis and skin thinning from very potent topical steroids

roids to put on which part of the body and for how long. While every effort should be made to make an accurate diagnosis before commencing topical steroids this is not always possible or practical. Once skin infection, infestation, malignancy, rosacea and perioral dermatitis can rule out, it is usually quite safe to give a trial of topical steroids. Topical steroids should not be put in or near varicose ulcers. Table  63.2 shows possible reasons why topical steroids are not working (Fig. 63.2).

63.3 Potency Mild and moderately potent steroids (Table 63.3) are considered safe on the body, even on children. 1% Hydrocortisone cream is considered so safe it can be purchased over the counter in the pharmacy without a prescription from a doctor. 1%

63  Steroids in Dermatology Table 63.2 Possible reasons why apparent steroid responsive dermatoses fail to respond to topical steroids include • Too little or too weak (e.g. parental or medic anxiety about steroids) • Too strong or too much (= telangiectasia or atrophy) • Emollients = not enough or not greasy enough • Irritants = too much • Disease is too severe (may need UVB or systemic treatment) • Infected: e.g. bacterial (impetigo), viral (herpes or varicella-zoster), fungal (tinea) • Infestation (e.g. scabies) • Allergies (Contact allergic dermatitis, foods, drugs, gluten, HDM, to steroid base, etc) • Underlying diseases: Varicose veins, renal or liver failure, thyroid disease, iron deficiency, diabetes, HIV, pregnancy, para-neoplastic, lupus, etc • Incorrect diagnosis (e.g. neoplasm such as Bowen’s disease, urticaria, pre-bullous pemphigoid etc) • Psychogenic causes: delusion of infestation, dermatitis artefacta • Used on a steroid aggravated skin condition such as peri-oral dermatitis or rosacea

Fig. 63.2  Worsening of tinea paedis (tinea incogneta) from applying a very potend topical steroid

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hydrocortisone is considered so weak (600 times weaker than clobetasone) that it is of little help on the body, hands or feet in adults. Potent TS should be avoided in children and very potent TS should never be used in children. Potent TS should be avoided on the face and flexures in children and adults. Very potent steroids are safe on the body in adults who may require them for troublesome corticosteroid-responsive dermatoses, provided they are used in relatively small quantities (e.g. 60 g/month for chronic use; larger amounts can be used for short term use) (Table 63.4). Many patients get a weak TS for the face (e.g. 1% Hydrocortisone) and a moderately potent (in children) or potent (in adults) TS for the body. Patients often get confused with the percentages of the various TS commonly available. For instance, clobetasol propionate 0.05% (“Dermovate Ointment®”) is a lot more potent than betamethasone valerate 0.1% (“Betnovate ointment®”) which in turn is a lot more potent than 1% hydrocortisone ointment. Stronger steroids will usually induce a rapid remission which can then be maintained with the less potent varieties (the step down approach). Alternatively, reducing the potent topical steroid to twice a week on the areas that tend to flare up during exacerbations (e.g. the backs of the knee and front of the elbows) may help maintain the improvement long term. Sometimes potent or super potent topical steroids may have to be continued for a few months in conditions like vitiligo. In this situation, it might be safer to use them

Table 63.3  Topical steroid potency Potency Super potent Potent

Moderately potent Weak

Example Clobetasol propionate Betamethasone(as valerate) Betamethasone dipropionate Hydrocortisone butyrate Mometasone furoate Hydrocortisone butyrate Alclometasone dipropionate Hydrocortisone 0.1–2.5%

Trade Names “Dermovate®” “Betnovate®”. “Diprosone®”. “Locoid®”. “Elocon®”. “Eumovate®”. “Modrasone®”. 1% hydrocortisone. “Dioderm®”

Potency ratio 600 100

25 1

D. Buckley

570 Table 63.4  Maximum amount of topical steroids per month for chronic usea Potency Mild Moderate Potentb Very potent

Age adult No max 200 g 90 g 30–60 g

12 years No max 100 g 30 g Avoid

3 years 200 g 60 g 15 g. For acute use only Avoid

Infant 7 mm) Bleeding or crusting Inflammation.

Non-melanoma skin cancers—These include basal cell carcinomas (BCC) and squamous cell carcinoma (SCC). SCCs grow slowly and rarely spread beyond the skin unless they are neglected for a long time. BCC’s almost never spread beyond the skin so they are not usually fatal. However, they can spread locally within the skin and cause troublesome ulcers or damage local structures such as the eyes, ears or lips. The warning signs to look out for are as follows: • A new growth on the skin, which appears for no apparent reason. • A sore or an ulcer that will not heal after 2–4 weeks. • A persistent isolated scaly patch on the skin that does not clear up with topical creams. Many people just notice a bump that looks like a mosquito bite but does not heal. It grows slowly and sometimes bleeds when scrubbing with the towel. If you have any of these warning signs please get your doctor to check your skin.

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66.6.5 Warning signs for melanoma • A mole that suddenly gets bigger in size (diameter) or you develop a brand new mole on your skin that continues to grow. (Change in size) • The mole develops a ragged or uneven outline (moles are normally round or oval and have a smooth edge). (Change in shape) • The mole develops a mixture of different shades of brown, black or other colours through it (normal moles usually have only one colour and the colour does not change over time) (Change in colour) • The mole looks completely different than the rest. (“the ugly duckling sign”) • The mole becomes red or inflamed around the edges. • The mole starts bleeding, oozing or crusting. • The mole starts to feel different, for example, slightly itchy or painful. • Not all melanomas are brown or black—they may be flesh coloured, red or pink. Any new or changing lesion on the skin that you cannot explain needs to be checked by a doctor with experience in dermatology.

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66.7 Skin Surgery 66.7.1 Anticoagulants and surgery-patient information If you are taking blood thinners prior to surgery please discuss whether you need to stop, reduce or delay your dose with your surgeon. We normally recommend the following: Aspirin (ASA) is often taken by patients without clear indication (e.g. post heart attack or stroke or post-stenting or bypass surgery) in which case it can be stopped 10–14 days before surgery. Otherwise it is unlikely to cause significant bleeding problems in isolation at 75–300 mg daily. If you are having medium or high risk skin surgery discuss with your GP if it is safe to stop your aspirin 10–14 days before your surgery for full reversal or 5 days for 50% efficacy. Restart 7 days post-surgery. Clopidogrel (“Plavix”®) cause prolonged oozing. Postpone surgery until off drug if possible (e.g. sometimes used for 1 year post cardiac stinting or bypass). If you are having a high bleeding risk procedure ask the cardiologist’s or GP’s advice regarding the risk of stopping clopidogrel for 7 days before your surgery and if a substitute alternative drug should be used while off the drug. Restart 7 days after your surgery. Warfarin: Stopping or avoiding warfarin is not usually justified. Check INR bloods 72 h before your surgery. The bleeding risk is very small if the INR is